Differential diagnosis
- Hemorrhoids
- Fissure
- Proctalgia fugax
- Anorectal abscess
- Fistula-in-ano
- Pilonidal disease
- Rectal prolapse
- Anal neoplasm
History
- Pain – OLDSCARS
- Bleeding
- Lumps, palpable cord, prolapse
- Drainage
- Stool changes
Physical
- Rectal exam – fissure, sentinel pile, hemorrhoids, masses, fistula’s
Goodsall’s rule = fistula’s originating anterior to transverse line will course straight ahead and exit anteriorly; those exiting posteriorly have a curved tract.
PMHx: Ask about Crohn’s, ulcerative colitis, past surgical history, medicaitons, allergies
Treatment:
- Fistula: marsupializaion of tract, wound care, seton
- Fissure: sentinel pile, fissure, hypertrophies papilla; treat with fiber, diltiazem, botox, sphincterotomy
- Abscess: incision and drainage, no antibiotics – may develop fistula