RECTAL PAIN
Practically the whole specialty of proctology is devoted to taking care
of patients with rectal pain. To develop the differential diagnosis it is
useful first to divide the conditions into extrinsic and
intrinsic. To recall the extrinsic causes, one simply
visualizes the structures around the rectum. Noting the tubes and ovaries,
one considers salpingitis, ovarian cysts, and ectopic pregnancy. Visualize
the coccyx, and coccydynia is brought to mind. Just as important a cause of
rectal pain is prostatitis or prostatic abscess. A pelvic appendix or
ruptured diverticulum may inflame the rectum extrinsically.
Intrinsic causes are developed by the mnemonic VINDICATE.
V—Vascular conditions suggest hemorrhoids.
I—Inflammation suggests proctitis, anal ulcers, and perirectal
abscess.
N—Neoplasms are not usually painful until the advanced stage of
disease.
D—Degenerative disorders are suggested,
but there are no degenerative diseases causing rectal pain.
I—Intoxication includes overuse of suppositories and
phenylephrine HCl (Preparation H).
C—Congenitaland acquired malformations suggest fistula in ano,
diverticulum, and intussusception.
A—Autoimmunediseases suggest ulcerative proctitis and
granulomatous colitis.
T—Trauma should bring to mind fecal impactions and foreign bodies
or introduction of the male organ into the rectum.
E—Endocrine disorders suggest nothing other than the ovarian
cysts and ectopic pregnancy already mentioned.
Approach to the Diagnosis
The cause of rectal pain is usually obvious on examination with an
anoscope or proctoscope. Careful palpation may be necessary to discover a
perirectal abscess, coccydynia, or an ectopic pregnancy. Anal fissures may
be missed unless all quadrants of the anus are examined with the slit
anoscope.
Other Useful Tests
-
Proctology consult
-
Sigmoidoscopy (rectal carcinoma)
-
Stool culture (proctitis)
-
Barium enema (Crohn disease, ulcerative colitis)
-
Frei test (lymphogranuloma venereum)
-
Prostatic massage and examination of the exudate (proctitis)
-
Urine culture and colony count
-
X-ray of lumbar spine (cauda equina syndrome, coccydynia)
-
HIV antibody titer (AIDS)
-
Gallium scan (perirectal abscess)
-
Pregnancy test
-
Pelvic sonogram (ectopic pregnancy)
-
Sedimentation rate (pelvic inflammatory disease [PID])
Pictures
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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