Small Print:Urinalysis, ultrasound, hospital-based lower GI investigations
FBC/ESR/CRP: WCC may be raised in abscess and Crohn’s disease. ESR/CRP raised in these and carcinoma.
Proctoscopy valuable if pain allows (specialist might also take biopsy).
Faecal calprotectin: May help in diagnosing Crohn’s disease.
Urinalysis: Pus cells and blood may be present in prostatitis or invasive bladder tumour
Ultrasound of pelvis if pelvic examination reveals a mass. In obscure cases, hospital-based lower GI investigations may be needed.
If the patient uses dramatic language (e.g. red-hot poker) to describe fleeting pain, is otherwise well and there are no obvious abnormalities on examination, the diagnosis is likely to be proctalgia fugax.
Examine the patient – the cause is usually a thrombosed pile/perianal haematoma, anal fissure or an abscess, and these can usually be diagnosed by simple inspection
Provide symptomatic relief but remember to deal with any underlying causes – especially constipation.
Don’t forget to ask about thirst and urinary frequency – recurrent abscesses may be the first presentation of diabetes.
Preceding weight loss and/or change in bowel habit should prompt a full urgent assessment with carcinoma and inflammatory bowel disease in mind.
Some perianal abscesses do not result in external swelling. If PR exam is prohibitively painful, consider this possibility – especially if the patient is febrile
In florid or recurrent perianal problems, think of Crohn’s disease as a possible cause.
Remember rarer causes in intractable, constant pain in a patient with no obvious signs on PR.
The experts behind Pulse Reference are Dr Keith Hopcroft who is the co-author of Symptom Sorter, a GP in Essex and Pulse’s editorial advisor and Dr Poppy Freeman, a GP in Camden and also a clinical advisor to Pulse.
This website is for clinical guidance only and cannot give definitive diagnostic information. Practitioners should work within the limits of their individual professional practice, seek guidance when necessary and refer appropriately.
The AI platform ChatGPT has assisted in the creation of some of the content published as part of Pulse Reference. Dr Hopcroft and Dr Freeman have then thoroughly reviewed the content to ensure its timeliness and reliability.