Related Subjects:
|Rectal Prolapse
|Anal Cancer
|Anal Fissure
|Perianal symptoms
|Perianal abscesses and fistulae
|Pilonidal Abscess (sinus)
|Haemorrhoids (Piles)
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.
