Rectal pain

The most commonly complained of rectal pain is intermittent severe rectal pain that is not associated with defecation but may wake the sleeping patient. It is difficult to explain and does not usually result from organic disease. In men prostatitis is a common cause of rectal pain: symptoms include perianal pain. Rectal pain will be worse on defecation (Hopcroft & Forte, 2003).

Pelvic pain

Pelvic pain is a common presentation in women. Pelvic Inflammatory Disease, ectopic pregnancy, endometriosis, ovarian pathology, uterine/cervical cancer and other gynaecological conditions need to be excluded. Often there is no obvious cause found, and often the pain can be a variant of the irritable bowel syndrome (Hopcroft & Forte, 2003).

In the event of no obvious cause, work with the patient to see if there is any underlying cause: are there any pressures relating to sex or any physiological problems, and refer appropriately.

TENESMUS

. . . is the feeling of incomplete evacuation or a frequent sensation of the need to evacuate. Diarrhoea is often commonly associated, whether it has a functional or an organic cause. These can be signs of rectal disease, including rectal tumours or a large polyp, and can form unpleasant symptoms in ulcerative proctitis (Rhodes & Hsin, 1995).

The rectal ulcer

Syphilis, lympho-granuloma venereum (LGV), or even a solitary herpetic lesion can be the cause (Holmes et al., 1990; Morse et al., 2003). Take appropriate specimens for culture and investigation. The single ulcer causing tenes-mus is often related to rectal mucosal prolapse, which would need the intervention of a gastroenterologist or a surgeon (Rhodes & Hsin, 1995).

DISCHARGE

Spontaneous discharge of pus can indicate a sexually transmitted infection or anal or rectal disease. Examination and appropriate specimens should be obtained. Careful inspection should reveal anal tumours, fissuring, and perianal fistula or perianal infections such as perianal warts, syphilitic chancre, and herpetic ulceration (Holmes et al., 1990; Morse et al., 2003).

INCONTINENCE

Incontinence can occur in the presence of a normal sphincter if there is severe diarrhoea. Consultation is needed to assess recent travel abroad, recent diet or change in sexual partner and current sexual practices. The clinician should obtain a stool sample for microscopy and culture. Blood tests for Hepatitis A, B, and C should he undertaken (BASHH, 2005a), but these tests usually do not have an early detection rate, so there should be referral to a senior doctor or an infectious diseases unit if there are other hepatic symptoms and/or hepatitis is suspected. Usually, however, diarrhoea is due to poor sphincter function. Diagnosis depends on an assessment of the three components of sphincter function, the puborectalis sling, the internal and the external sphincter. Incontinence can be related to obstetric trauma, which may have gone unnoticed immediately following the birth.

ANAL LESIONS

Sexually transmitted infections need to be considered in anal lesions/ulceration. Herpetic ulcers/lesions can cause tenesmus and severe pain (BASHH, 2001b; Morse et al., 2003), whereas the syphilitic ulcers/lesions known as chancres are painless in nature (BASHH, 2002b; Holmes et al., 1990). Herpetic lesions/ulcers may look like clusters of blisters or healing sores, but often their appearance can be atypical. With syphilitic lesions in primary syphilis there is often one solitary circular sore; but again this is not always the case. Swabs for Herpes simplex virus, microscopy and culture should be obtained, and dark-ground microscopy should be performed on wet mounts of serum and saline for Treponema pallidum as well as syphilis serology, which may have to be repeated in early suspected syphilis. Condylomata lata are mucosal lesions in secondary syphilis and tend to have a flatter appearance than anal warts, which are more papilliferous by nature (Holmes et al., 1990; Morse et al., 2003).

Fissured, macular and ulcerating lesions should be biopsied. Paget's and Bowen's diseases can only be diagnosed via histology, and are malignant diseases. Fistulas and perianal abscesses are easy to diagnose on examination. A main problem with this manifestation is not to recognise the possibility of underlying Crohn's disease, especially with the presence of thickened purplish skin tags, and another failing can be to assess the full extent of the fistula inaccurately. Further investigation by a specialist is commonly needed (Rhodes & Hsin, 1995).

The possibility of malignant tumours' being present in the anal canal means that there is a need for the exclusion of carcinomatous diseases: appropriate investigation, referral and management must be carried out.

ANAL WARTS

... are generally sexually transmitted and should alert suspicion to other sexually transmitted infections' being present. Offering a routine sexual health screen to all attending patients complaining of rectal symptoms can exclude these (BASHH, 2002a).

MOLLUSCUM CONTAGIOSUM

Molluscum contagiosum (MC) is caused by a pox virus and typically presents as umbilicated papular lesions: they are quite distinctive, and can be diagnosed on examination. MC is normally sexually transmitted in adults through skin to skin contact (Holmes et al., 1990; BASHH, 2003).

ANAL FISSURES

Patients may complain of severe pain during defecation, sometimes associated with bright red rectal bleeding. Fissures can be easily diagnosed by examination; however, all fissures in men who have sex with men should be screened for LGV, dark ground microscopy on three samples is recommended and syphilis serology.

ANAL TAGS

Anal tags are normal skin variation, and though they do not cause any symptoms or require treatment, sometimes they may be a clue to an underlying condition. As has earlier been stated, tags can be associated with Crohn's disease: these tags are usually thick with a purplish appearance. Anal tags can occur as the result of a thrombosed external pile or may form the marked end to a chronic anal fissure.

PRURITUS

Patients complaining of perianal itching should be further questioned to assess if there are other symptoms such as pain, discharge, rashes or bumps or any sexual contact or family member with similar symptoms. The perianal area and anus should be examined for genital warts, which often cause itching. Is there inflammation in the area? Could there be a candidal infection? Is there similar inflammation and excoriation in other genital areas, the vulva, the penis? With women, is there a thick creamy discharge from the vagina? Appropriate samples should be obtained for analysis.

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