A Man with Rectal Pain

Published - Written by Carla Rothaus

Conditions that have a similar appearance to hemorrhoids include skin tags (which may be tender if they are associated with Crohn’s disease or chronic fissures), condylomata acuminata, condylomata lata, and anal tuberculosis. A 33-year-old man presented with painful bowel movements and rectal bleeding. Physical examination and sigmoidoscopy revealed sentinel skin tags, multiple fissures, and mucosal inflammation of the distal rectum. A diagnosis was made in a new Case Record article.

Clinical Pearls

Q: What clinical findings suggest that an anal fissure may be due to underlying systemic disease?

A: In describing anal fissures, the number and location matter. Most fissures are due to mechanical stress; 90% are located in the posterior midline, and 8% in the anterior midline. The presence of fissures in the lateral midline or of multiple fissures makes underlying systemic disease more likely.

Q: What are the typical symptoms of proctitis?

A: Proctitis typically causes symptoms such as dyschezia, as well as urgency, tenesmus, and anal discharge. Proctitis is distinct from colitis, which is inflammation of the colon proximal to the rectum. Colitis is usually associated with symptoms such as diarrhea, abdominal pain, bloating, and weight loss. Some conditions cause either proctitis or colitis and others can cause both; the anatomical location of the inflamed region dictates the symptom profile.

Morning Report Questions

Q: What are some of the causes of proctitis that are associated with perianal findings?

A: Perianal abnormalities, including painful skin tags and fissures, are common among patients with Crohn’s disease. Two percent of patients with Crohn’s disease may present with isolated proctitis. Patients with lymphogranuloma venereum (caused by Chlamydia trachomatis serovar L1, L2, or L3) typically present with lymphadenitis. However, lymphogranuloma venereum causes an isolated proctitis without lymphadenitis in 83% of cases that are acquired by anogenital contact, and the secondary stage can mimic Crohn’s disease, with features including perianal fissures, fistulae, and abscesses. Lymphogranuloma venereum is an emerging cause of proctitis in the population of men who have sex with men (MSM) worldwide and is responsible for several outbreaks in Europe in the past 15 years. Although Neisseria gonorrhoeae and C. trachomatis (serovars D through K) are the two most common causes of proctitis among MSM (accounting for 30% and 19% of all infections, respectively), these infections typically do not cause chronic fissures or painful anal papules. Ulcerative colitis and lymphoid follicular proctitis typically do not cause perianal findings.

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Q: What are some of the reasons that a treatable cause of anal symptoms may be missed?

A: In MSM, symptoms attributable to anorectal infections are often mild or absent, whereas symptoms in the throat or urethra are more severe. Therefore, among MSM, even mild or ambiguous symptoms should prompt comprehensive testing, including urinary nucleic acid testing for gonorrhea and chlamydia and also rectal and pharyngeal culture and nucleic acid testing. Furthermore, MSM should be screened for sexually transmitted infections at regular intervals, even when they have no symptoms. The two most common reasons for missing a treatable cause of anal symptoms are that patients attribute their symptoms to hemorrhoids and that doctors believe them.

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