Makindo Medical Notes

Perianal symptoms are common in both primary care and surgical practice. They can range from benign and self-limiting conditions such as hemorrhoids, to serious pathology including abscesses, fistulae, or malignancy. A systematic approach is needed, combining careful history, examination, and appropriate investigations.

🔴 Perianal Pain

• Clinical Features: Severe, constant pain, often worse with sitting or defecation. May be associated with swelling, warmth, and redness.
• Causes: Perianal abscess, anal fissure, thrombosed hemorrhoid.
• Investigations: Clinical examination, digital rectal exam (DRE). Ultrasound or MRI if deep abscess suspected.
• Management:
  • Abscess → urgent incision and drainage.
  • Fissure → stool softeners, topical GTN or diltiazem, analgesia.
  • Thrombosed hemorrhoid → excision if acute, or conservative care (ice packs, analgesia).

💧 Perianal Discharge

• Clinical Features: Persistent or intermittent pus or fecal discharge, often with itching, skin irritation, or swelling.
• Causes: Perianal fistula, Crohn’s disease.
• Investigations: Clinical exam, DRE, MRI or endoanal ultrasound to map fistula tracts.
• Management:
  • Fistulotomy or seton placement.
  • Treat underlying IBD with immunosuppressive therapy.

🌙 Perianal Itching (Pruritus Ani)

• Clinical Features: Intense itching, worse at night or after bowel motions. Red, excoriated perianal skin.
• Causes: Contact dermatitis, fungal infection (candida), pinworm infestation.
• Investigations: Clinical exam, stool microscopy (pinworms), patch testing for dermatitis.
• Management:
  • Topical antifungal or mild steroid creams.
  • Anti-helminthics (e.g., mebendazole) for pinworms.
  • Avoid irritants, maintain hygiene, use cotton underwear.

📍 Perianal Swelling

• Clinical Features: Localized lump near the anus, may be tender with redness or pus drainage.
• Causes: Perianal abscess, thrombosed external hemorrhoid, rarely anal cancer.
• Investigations: Clinical exam, DRE, ultrasound for deeper collections.
• Management:
  • Abscess → incision and drainage.
  • Hemorrhoid → excision if severe, conservative otherwise.
  • Persistent or atypical → biopsy to exclude malignancy.

🩸 Perianal Bleeding

• Clinical Features: Bright red blood on toilet paper or in stool. Painful bleeding (fissure) vs painless bleeding (hemorrhoids).
• Causes: Anal fissure, hemorrhoids, IBD, rarely anal cancer.
• Investigations: Anoscopy or proctoscopy for fissures/hemorrhoids; colonoscopy if IBD, malignancy, or unexplained bleeding suspected.
• Management:
  • Fissure → stool softeners, topical therapy.
  • Hemorrhoids → rubber band ligation, sclerotherapy, or surgical excision.
  • IBD → immunosuppressive or biologic therapy.

📌 Key Points

• Always exclude anal cancer in persistent or atypical symptoms.
• Differentiate painful vs painless bleeding → fissure vs hemorrhoids.
• Perianal abscesses require urgent drainage, not antibiotics alone.
• Recurrent discharge → think of fistula or Crohn’s disease.