Anal Pain

Differential diagnosis

  • Hemorrhoids
  • Fissure
  • Proctalgia fugax
  • Anorectal abscess
  • Fistula-in-ano
  • Pilonidal disease
  • Rectal prolapse
  • Anal neoplasm


  • Pain – OLDSCARS
  • Bleeding
  • Lumps, palpable cord, prolapse
  • Drainage
  • Stool changes


  • 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


  • 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

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