RECTAL DISCHARGE

Rectal discharges are usually bloody, but the two notable exceptions to this are a ruptured perirectal abscess and an anal fistula (really the end result of the former). Use the mnemonic MINT, and a few other conditions that might otherwise be overlooked come to mind. M—Malformation that creates a nonbloody rectal discharge is loss of sphincter control, often due to rectal surgery or a deep midline episiotomy, but perhaps even more frequently due to neurologic disturbances such as spinal cord injury or stroke (really fecal incontinence). A pilonidal sinus, although not specifically related to the rectum, may suggest that the patient has a rectal discharge. I—Inflammation, in addition to those disorders already mentioned, recalls an anal fissure or ulcer that not only causes purulent material to weep on its own but also often permits fecal material to leak onto the underclothes of the patient. The fistulous tracts from regional ileitis and lymphogranuloma venereum must be considered here. Condyloma latum and acuminatum, although not causing a discharge themselves, may prevent complete closure of the anal canal and permit fecal material to leak. N—Neoplasms of the rectum and anus and even thrombosed hemorrhoids can behave in a similar manner.

T—Trauma is mentioned merely to remind one again of episiotomies and rectal surgery that may create poor control and allow chronic escape of feces, especially the liquid form.

Approach to the Diagnosis

Smear and culture of the discharge are axiomatic. Visualization of the lesion with the anoscope or sigmoidoscope is usually necessary. A Frei test should be done if lymphogranuloma venereum is suspected.

Other Useful Tests

1. CBC (inflammation, abscess)
2. Sedimentation rate (abscess)
3. VDRL test
4. Frei test (lymphogranuloma venereum)
5. Barium enema (ulcerative colitis)
6. Cystogram (fistulous tract)
7. Stool for ova and parasites (amebiasis)
8. Proctology consult
9. Computed tomography (CT) scan of pelvis (neoplasm, fistulous tract, abscess)
10. Indium scan (abscess)
11. Exploratory surgery
12. Biopsy of lesion
13. HIV antibody titer

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Book Source Details

• Book Title: Differential Diagnosis in Primary Care
• Author(s): R. Douglas Collins MD, FACP
• Year of Publication: 2007
• Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2007 Lippincott Williams & Wilkins.

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Copyright Details: Differential Diagnosis in Primary Care, Copyright © 2008 Williams & Wilkins.

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More About This Book: Title: Differential Diagnosis in Primary Care Authors: R. Douglas Collins MD, FACP Publisher: Lippincott Williams & Wilkins Copyright: 2007 ISBN: 0-7817-6812-8

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