Risk Factors/Etiology
- Hemorrhoids are more common in pregnancy and are associated with constipation
and straining bowel movements, obesity, and chronic liver disease. Internal hemorrhoids
are located above the dentate line and are painless. External hemorrhoids are
located below the dentate line and are painful.
- Anal fissures are the most common cause of painful rectal bleeding.
- Pilonidal cysts usually occur in young people and are a chronic recurring reaction to
an ingrown hair.
- Perirectal and perianal abscesses are common in diabetics and drug abusers.
Clinical Presentation and Diagnoses
- Internal hemorrhoids cause painless bright red blood with defecation. They are only
visible through an anoscope.
- External hemorrhoids cause pain with defecation and are usually visible on exam.
- Rectal bleeding must be referred for further evaluation for malignancy.
- Other causes of rectal pain include foreign body, venereal proctitis, trauma, abscesses,
and anal fissures.
- Anal fistulas present with malodorous bloody discharge through the fistula.
- Anal fissures present with painful bowel movements, with the pain resolving between
bowel movements.
- Perianal and perirectal abscesses present as a tender red mass and may have concurrent
fever and leukocytosis.
Treatment
- Most hemorrhoid patients may be managed conservatively with sitz baths, good hygiene,
bulk laxatives, and stool softeners. Thrombosed external hemorrhoids should
be referred to a surgeon, or may be excised and the clots removed in the ED if conservative
measures have failed.
- Surgical referral is needed for anal fistulas.
- Anal fissures may be treated conservatively with sitz baths and local analgesics.
- All but the most simple perianal abscesses should be drained and followed by a surgeon.
Perianal abscesses should be drained and packed, with antibiotics only necessary
in diabetics and other immunocompromised hosts.
- Most rectal foreign bodies can be removed in the ED after adequate analgesia. Antibiotics
and surgical or gastroenterological consultation should only be obtained in cases
of high risk or perforation or with peritoneal or other toxic signs.
- Pilonidal cysts may be drained and packed in the ED, with surgical referral appropriate
for definitive removal of the cyst.
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