Journal of Family Medicine and Primary Care

LETTER TO EDITOR
Year
: 2018  |  Volume : 7  |  Issue : 5  |  Page : 1139--1140

A painful anal lesion


Morteza Khodaee, Roxanne L Radi 
 Department of Family Medicine, University of Colorado School of Medicine, Denver, CO, USA

Correspondence Address:
Prof. Morteza Khodaee
Department of Family Medicine, A.F. Williams Clinic, University of Colorado School of Medicine, 3055 Roslyn Street, Denver, CO 80238
USA




How to cite this article:
Khodaee M, Radi RL. A painful anal lesion.J Family Med Prim Care 2018;7:1139-1140


How to cite this URL:
Khodaee M, Radi RL. A painful anal lesion. J Family Med Prim Care [serial online] 2018 [cited 2019 Oct 18 ];7:1139-1140
Available from: http://www.jfmpc.com/text.asp?2018/7/5/1139/245730


Full Text



Dear Editor,

A 27-year-old male presents with severe anal pain for the past 2 days. He complains of a “mass” around his anus. His bowel movements have been generally normal, but recently, they have been very painful. Even sitting causes significant discomfort. He denies any fevers, rectal bleeding, or any trauma to the area including anal sex. His past medical, surgical, and social histories are otherwise unremarkable. Examination shows a tender 4 cm × 2.5 cm × 1.5 cm lesion with some bluish spots at 9 o'clock which partially obstructs the external anal canal [Figure 1].{Figure 1}

After achieving local anesthesia with lidocaine 1%, using a no. 11 scalpel, multiple relatively large thrombi removed [Figure 2]. Patient immediately felt better after procedure.{Figure 2}

 Discussion



A painful atraumatic external anal lesion is a relatively uncommon condition. The differential diagnosis is summarized in [Table 1].[1],[2] A comprehensive evaluation beginning with history and physical examination is essential to an appropriate approach.{Table 1}

External hemorrhoids are usually painless; however, thrombosis of external hemorrhoids usually causes significant pain and discomfort acutely over a few days period.[1],[2] Patients often complain of constipation, bleeding, and pain without the presence of a fever.[1],[2] Physical examination reveals swollen, blue-purple tinted, and very tender external hemorrhoids. There is usually no discoloration or tenderness of surrounding tissue. Thrombectomy (a small incision after infiltration with local anesthesia with subsequent evacuation of the thrombi) within 3 days effectively alleviates the pain.[1],[2] Anesthetic creams or suppositories may help with the pain. Without thrombectomy, the pain usually subsides over a few days.[1]

Most perianal abscesses are cryptoglandular infections.[3] Patients usually present with gradual onset of pain and discomfort with or without fevers.[1],[2],[3] Drainage of pus may be present.[2] Recent diarrhea, constipation, and chronic diseases such as diabetes are predisposing factors for perianal abscess.[2],[3] Physical examination typically reveals an erythematous, tender, fluctuant, and indurated bulged lesion near the anus.[3] Incision and drainage are usually adequate to treat a perianal abscess. In some cases, systemic antibiotics may be necessary.[3]

Anal cancer is a relatively rare disease occurring in middle-aged adults.[4] It is more common among men who practice anal-receptive sexual intercourse and those with positive HIV status.[4] Squamous cell carcinoma is the most common type of anal cancer. Human papilloma virus (HPV) is the causative agent in the majority of anal cancers.[4] Patients usually present with a painless and slow growing mass with occasional bleeding.[4] Large tumors can cause anal obstruction. Weight loss may be present particularly in advanced stages of cancer.[4] On digital examination, enlarged perianal lymph nodes may be present.[4] Biopsy is required for diagnosis.

Perianal Crohn's disease is more common among children and usually manifests as anal fissures and skin tags.[5],[6] External anal skin tags appear as large, edematous (elephant ear), bluish or skin-colored masses caused by lymphatic obstruction.[5],[6] The pain and drainage are usually absent. Concomitant anorectal abscesses and fistula are relatively common in patients with anorectal Crohn's disease.[5] An endoanal ultrasonography and MRI can help make the diagnosis.[5]

Condylomata acuminate is a sexually transmitted disease caused by infection with HPV.[2],[6] They are slow-growing masses in patients with a history of anal intercourse.[1],[2] They are usually itchy; pain may or may not be present.[2] Typical findings on physical exam are gray-tan colored, cauliflower-like lesions in the perianal region that may become large.[1],[2],[6]

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician 2011;84:204-10.
2Fargo MV, Latimer KM. Evaluation and management of common anorectal conditions. Am Fam Physician 2012;85:624-30.
3Bach HH 4th, Wang N, Eberhardt JM. Common anorectal disorders for the intensive care physician. J Intensive Care Med 2014;29:334-41.
4Clark MA, Hartley A, Geh JI. Cancer of the anal canal. Lancet Oncol 2004;5:149-57.
5Strong SA. Perianal Crohn's disease. Semin Pediatr Surg 2007;16:185-93.
6Opar SP. Photo quiz. Painful perianal lesions. Am Fam Physician 2010;82:419-21.