Skip to main content
Symptom
dx.
Menu
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Calculators
Clinical calculators
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Symptom
dx.
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Calculators
Clinical calculators
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Get Started
Menu
Clinical Reference
Approaches
I have a symptom
Management
I know the diagnosis
Orthopedic Injuries
Fractures & dislocations
Calculators
Clinical calculators
Practical Skills
ECG
Interpretation guide
POCUS
Bedside ultrasound
Procedures
Step-by-step guides
Resuscitation
ACLS / PALS / NRP
Learn
Blog
Articles & updates
Deep Dive
In-depth clinical reviews
About
Our mission
Loading...
Rectal Pain and Anorectal Complaints
Resuscitation and Universal Approaches
Approach to Unresponsive Patient
Approach to Airway Obstruction And Stridor
Approach to Acute Respiratory Distress With Impending Failure
Approach to Peri-arrest Hypotension
Approach to Post Resuscitation Care After Rosc
Approach to Cardiac Arrest Rhythms, Pea, Asystole
Approach to Cardiac Arrest Rhythms, Vf, Pulseless Vt
Approach to Severe Agitation With Safety Risk
Approach to Procedural Sedation
Chest and Cardiovascular
Approach to Pacemaker And Icd Related Presentations
Approach to Acute Limb Ischemia And Leg Pain
Approach to Suspected Deep Vein Thrombosis Symptoms
Approach to Hypertension
Approach to Chest Pain
Approach to Palpitations And Tachyarrhythmia Symptoms
Approach to Bradycardia Symptoms
Approach to Syncope And Presyncope
Approach to Syncope With Neurologic Concern
Approach to Unilateral Leg Swelling
Approach to Bilateral Leg Swelling
Approach to Calf Pain And Swelling
Respiratory
Approach to Wheezing, Undifferentiated
Approach to Wheezing In Infants
Approach to Stridor And Upper Airway Symptoms
Approach to Dyspnea
Approach to Aspiration Event
Approach to Cough
Approach to Hemoptysis
Approach to Upper Respiratory Infection Symptoms
Approach to Suspected Pulmonary Embolism Presentation
Approach to Smoke Inhalation Concern
Approach to Smoke Exposure And Inhalational Injury
Abdominal and Gastrointestinal
Approach to Abdominal Distension
Approach to Abdominal Pain, Undifferentiated
Approach to Acute Abdominal Pain (general)
Approach to Suspected Incarcerated Or Strangulated Hernia
Approach to Pancreatitis Concern
Approach to Biliary Colic And Cholecystitis Concern
Approach to Appendicitis Concern
Approach to Diverticulitis Concern
Approach to Rectal Pain And Anorectal Complaints
Approach to Dysphagia And Food Bolus Impaction
Approach to Foreign Body Ingestion
Approach to Refractory Vomiting And Recurrent Vomiting Syndromes
Approach to Cannabis Associated Hyperemesis
Approach to Upper Gastrointestinal Bleeding Symptoms (melena)
Approach to Lower Gastrointestinal Bleeding And Hematochezia
Approach to Constipation And Obstipation
Approach to Diarrhea
Approach to Acute Hepatitis And Jaundice Concern
Approach to Right Upper Quadrant Pain
Approach to Epigastric Pain
Approach to Left Upper Quadrant Pain
Approach to Right Lower Quadrant Pain
Approach to Left Lower Quadrant Pain
Approach to Suprapubic Pain
Renal and Urinary
Approach to Oliguria And Anuria
Approach to Catheter Related Urinary Complaints
Approach to Dialysis Patient Presentations
Approach to Flank Pain And Renal Colic Concern
Approach to Urinary Retention
Approach to Hematuria
Approach to Scrotal Pain
Neurologic
Approach to Transient Neurologic Deficits
Approach to Acute Aphasia And Speech Disturbance
Approach to Acute Confusion And Delirium
Approach to Postictal State And Seizure Recurrence Concern
Approach to Seizure
Approach to Acute Vision Loss
Approach to New Tremor And Involuntary Movements
Approach to Headache
Approach to Vertigo
Approach to Acute Weakness Or Numbness
Approach to Gait Instability And Ataxia
Back and Neck
Approach to Atraumatic Back Pain
Approach to Sciatica And Radicular Back Pain
Approach to Back Pain With Neurologic Deficit, Cauda Equina Concern
Approach to Back Pain With Fever Or Immunosuppression, Spinal Infection Concern
Approach to Atraumatic Neck Pain
Approach to Neck Pain After Trauma
Approach to Neck Pain With Meningismus Concern
Approach to Acute Torticollis
Women's Health, Pregnancy, and GU
Approach to Vaginal Discharge
Approach to Hyperemesis Gravidarum Concern
Approach to Hypertensive Disorders Of Pregnancy Symptoms
Approach to Postpartum Hemorrhage Concern
Approach to Postpartum Infection Concern
Approach to Sexual Assault Medical Evaluation Overview
Approach to Pelvic Pain
Approach to Vaginal Bleeding, Nonpregnant
Approach to Vaginal Bleeding In Pregnancy
Approach to Pelvic Pain In Pregnancy
Approach to Post Procedure Or Post Abortion Complications Concern
Infectious Disease and Fever Syndromes
Approach to Fever In The Immunocompromised Patient
Approach to Fever With Rash
Approach to Animal Bites And Rabies Risk Assessment
Approach to Tick Exposure And Tick Borne Illness Concern
Approach to Sepsis Concern Without Clear Source
Approach to Soft Tissue Infection Concern
Approach to Abscess And Skin Infection Concern
Approach to Sore Throat
Approach to Sore Throat And Pharyngitis Symptoms
Approach to Meningitis
Approach to Envenomation And Bites
Allergy and Dermatology
Approach to Pruritus Without Rash
Approach to Contact Dermatitis And Eczema Flare
Approach to Herpes Zoster Concern
Approach to Drug Eruption Concern And Severe Cutaneous Reaction Red Flags
Approach to Urticaria
Approach to Angioedema Concern
Approach to Unexplained Bruising Or Bleeding Symptoms
Musculoskeletal and Extremities
Approach to Shoulder Pain
Approach to Elbow Pain
Approach to Wrist Pain
Approach to Hand Pain
Approach to Hip Pain
Approach to Knee Pain
Approach to Ankle Pain
Approach to Foot Pain
Approach to Cast Or Splint Complication Symptoms
Approach to Wound Check And Suture Related Visits
Approach to Joint Swelling And Monoarthritis
Approach to Suspected Septic Joint Presentation
Approach to Suspected Tendon Rupture Presentation
Approach to Limp Or Refusal To Bear Weight
Trauma and Wounds
Approach to Motor Vehicle Collision Evaluation
Approach to Chest Wall Trauma And Rib Injury
Approach to Blunt Abdominal Trauma Evaluation
Approach to Penetrating Trauma Evaluation
Approach to Pediatric Minor Head Trauma
Approach to Pediatric Head Trauma
Approach to Facial Lacerations And Dental Trauma
Approach to Hand Lacerations With Tendon Injury Concern
Approach to Puncture Wounds And Retained Foreign Body Concern
Approach to Electrical Injury
Approach to Burn Injury
Approach to Fall Evaluation
Approach to Assault And Interpersonal Violence Evaluation
Approach to Eye Trauma And Hyphema Concern
ENT, Eye, Dental
Approach to Dysphagia And Odynophagia
Approach to Throat Pain
Approach to Ear Pain
Approach to Foreign Body In Ear Or Nose
Approach to Vision Loss Complaint
Approach to Flashes And Floaters
Approach to Atraumatic Eye Pain
Approach to Red Eye
Approach to Dental Abscess Concern
Approach to Post Extraction Pain And Complications
Endocrine, Metabolic, and Abnormal Labs
Approach to Hyperglycemia
Approach to Hypoglycemia
Approach to Hyponatremia Symptoms
Approach to Hyperkalemia Symptoms
Approach to Hypokalemia Symptoms
Approach to Rhabdomyolysis Concern
Approach to Anticoagulation Related Abnormal Coagulation Studies
Approach to Acute Kidney Injury And Elevated Creatinine Referral
Approach to Symptomatic Anemia Concern
Toxicology and Behavioral
Approach to Undifferentiated Overdose
Approach to Opioid Toxicity
Approach to Opioid Withdrawal
Approach to Alcohol Intoxication
Approach to Alcohol Withdrawal
Approach to Stimulant Toxicity
Approach to Pediatric Ingestion
Approach to Carbon Monoxide Exposure
Approach to Inhalational Or Chemical Exposure
Approach to Suicidal Ideation And Self Harm Risk Assessment
Approach to Acute Psychosis And Mania Symptoms
Approach to Anxiety And Panic Symptoms
Approach to Capacity Assessment And Safe Disposition
Approach to Behavioral Escalation And Restraint Considerations
Pediatrics
Approach to Fever In The Neonate And Young Infant
Approach to Pediatric Fever By Age 0 To 28 Days
Approach to Pediatric Fever By Age 29 To 60 Days
Approach to Pediatric Fever By Age 2 To 24 Months
Approach to Pediatric Respiratory Distress
Approach to Croup And Stridor In Children
Approach to Pediatric Dehydration
Approach to Pediatric Abdominal Pain
Approach to Febrile Seizure
Approach to Rash In The Child
Approach to Poor Feeding And Lethargy In The Infant
Approach to Vomiting In The Child
Approach to Diarrhea In The Child
Approach to Pediatric Trauma Evaluation
Approach to Brief Resolved Unexplained Event In The Infant And Apparent Life Threatening Event Concern
Approach to Lethargy And Altered Mental Status In The Child
Environmental and Exposure
Approach to Heat Illness
Approach to Hypothermia And Cold Exposure
Approach to Frostbite Concern
Approach to Drowning And Submersion Injury
Rectal Pain and Anorectal Complaints
POCUS
Procedures
Calculators
Resuscitation
ECG Guide
Back
Clinical Assessment Checklist
Browse categories and answer follow-up questions to refine your symptom profile.
History
Presenting concern
Symptom characterization
▶
Rectal pain onset
Pain relationship to defecation
Pain at rest
Pain after bowel movement duration
Pain severity trajectory
Bleeding pattern
Blood on paper
Blood in bowl
Blood mixed with stool
Discharge
Purulent
Mucus
Pruritus ani
Tenesmus
Stool frequency change
Stool caliber change
Constipation pattern
Diarrhea pattern
Fecal incontinence
Urinary retention symptoms
OPQRST
OPQRST framework
▶
Onset
▶
Sudden onset
Gradual onset
After constipation episode
After diarrhea episode
After anal intercourse
After instrumentation
Provocation and palliation
▶
Worse with bowel movement
Worse with sitting
Worse with walking
Worse with coughing
Relief with warm baths
Relief with topical anesthetic
Relief with stool softening
Quality
▶
Sharp
Tearing
Throbbing
Pressure
Burning
Region and radiation
▶
Anal verge
Rectal deep pain
Perineal
Radiates to sacrum
Radiates to genital region
Severity
▶
Pain score 0 to 10
Functional limitation
Timing
▶
Constant
Intermittent
Episodic with bowel movement
Nocturnal pain
Associated symptoms
Associated symptoms cluster
▶
Fever
Chills
Nausea
Vomiting
Abdominal pain
Pelvic pain
New back pain
Weight loss
Night sweats
Fatigue
Genital lesions
Dysuria
Vaginal discharge
Urethral discharge
New rash
Bowel history
Bowel pattern and triggers
▶
Baseline bowel frequency
Recent constipation duration
Straining
Hard stool episodes
Recent diarrhea duration
Recent antibiotic exposure
Recent travel exposure
Laxative use
Enema use
Infectious and sexual exposure history
Exposure risks
▶
Recent receptive anal sex
Barrier use
New sexual partners
Prior STI history
HIV status
Immunosuppression status
Sick contacts with diarrhea
Prior episodes and baseline
Prior anorectal disease history
▶
Prior fissure
Prior hemorrhoids
Prior perianal abscess
Prior fistula
Prior inflammatory bowel disease
Prior pelvic radiation
Prior colorectal neoplasm
Alarm Features
Immediate escalation triggers
Life threatening indicators
▶
Hemodynamic instability
▶
Systolic BP less than 90 mmHg
MAP less than 65 mmHg
HR greater than 120
Sepsis physiology
▶
Temperature 38.0 C or higher
Temperature less than 36.0 C
RR 22 or higher
New confusion
Significant GI bleeding
▶
Ongoing large volume hematochezia
Syncope
Orthostasis
Hemoglobin drop concern
Perineal necrotizing infection concern
▶
Severe pain out of proportion
Rapid progression hours
Skin discoloration
Bullae
Crepitus
Toxic appearance
Acute urinary retention
▶
Inability to void
Suprapubic fullness
Suspected rectal perforation
▶
Severe abdominal pain
Peritonitis
Free air concern
High risk historical features
Cancer and inflammatory red flags
▶
Unintentional weight loss
Persistent change in bowel habits
New iron deficiency anemia concern
Family history colorectal cancer
Age 50 or older with new bleeding
Immunocompromised state
Anticoagulant use with bleeding
High risk exam findings
Exam red flags
▶
Peritonitis
Fluctuant perianal mass
Extensive cellulitis
Anal canal mass
Rectal mass
Gross purulence
Severe tenderness limiting exam
Medications
Medication reconciliation
Current and recent medications
▶
Anticoagulants
▶
Warfarin
Apixaban
Rivaroxaban
Dabigatran
Edoxaban
Antiplatelets
▶
Aspirin
Clopidogrel
Ticagrelor
NSAIDs
Opioids
Constipating agents
▶
Anticholinergics
Calcium channel blockers
Iron
Immunosuppressants
▶
Systemic corticosteroids
Biologics
Chemotherapy
Recent antibiotics
Topical anorectal agents
▶
Lidocaine topical
Hydrocortisone topical
Nitroglycerin ointment
Diltiazem topical
Allergy and interaction risks
Contraindication and interaction screen
▶
Nitrate contraindication
▶
PDE5 inhibitor use within 24 to 48 hours
Hypotension
NSAID cautions
▶
CKD
Anticoagulation
GI bleeding history
Opioid cautions
▶
Respiratory depression risk
Severe constipation risk
Diet
Intake and bowel related triggers
Recent diet pattern
▶
Low fiber pattern
Dehydration risk
Recent reduced oral intake
Caffeine excess
Alcohol exposure
Spicy food trigger pattern
Recent fasting
Review of Systems
System review
ROS focused
▶
Constitutional
▶
Fever
Chills
Weight loss
Night sweats
GI
▶
Abdominal pain
Nausea
Vomiting
Diarrhea
Constipation
Hematochezia
Melena
GU
▶
Dysuria
Urinary retention
Hematuria
Skin
▶
Perianal rash
Vesicles
Ulcers
Neuro
▶
New weakness
Saddle anesthesia
New incontinence
Collateral History and Family History
Collateral and family risk
Additional context
▶
Collateral source reliability
Family history colorectal cancer
Family history inflammatory bowel disease
Household outbreak diarrhea
Risk Factors
Patient specific risks
Risk stratification
▶
Inflammatory bowel disease
▶
Crohn disease
Ulcerative colitis
Diabetes mellitus (E11.9)
HIV infection (B20)
Neutropenia
Pregnancy
Older age
Chronic constipation
Recent anorectal instrumentation
Recent pelvic radiation
Anticoagulation
Exposure risks
Exposure history risks
▶
Receptive anal intercourse
New sexual partners
STI exposure
Recent antibiotic exposure
Recent travel related diarrhea risk
Differential Diagnosis
Life threatening
Cannot miss diagnoses
▶
Fournier gangrene (N49.3)
▶
Pain out of proportion
Crepitus
Rapid progression
Sepsis physiology
Perirectal abscess with sepsis (K61.1)
▶
Fever
Fluctuant mass
Severe constant pain
Lower GI hemorrhage with shock (K92.2)
▶
Large volume hematochezia
Syncope
Rectal perforation
▶
Peritonitis
Recent instrumentation
Ischemic proctitis
▶
Severe rectal pain
Bloody diarrhea
Vascular risk factors
Cauda equina syndrome (G83.4)
▶
Saddle anesthesia
New urinary retention
New fecal incontinence
Common
Common anorectal etiologies
▶
Anal fissure (K60.2)
▶
Sharp tearing pain with bowel movement
Small volume bright red blood
Thrombosed external hemorrhoid (K64.5)
▶
Acute perianal lump
Severe focal pain
Hemorrhoids internal (K64.8)
▶
Painless bleeding pattern
Prolapse symptoms
Perianal abscess (K61.0)
▶
Constant throbbing pain
Fluctuance
Proctitis infectious
▶
Rectal pain
Tenesmus
Mucopurulent discharge
Constipation with fecal impaction (K56.41)
▶
Overflow diarrhea
Rectal fullness
Less common
Less common and mimics
▶
Rectal cancer (C20)
▶
Weight loss
Change in bowel habits
Iron deficiency anemia concern
Anal cancer (C21.0)
▶
Anal mass
Persistent pain
Rectal prolapse (K62.3)
▶
Protruding tissue
Incontinence
Solitary rectal ulcer syndrome
▶
Straining
Rectal bleeding
Endometriosis involving bowel
▶
Cyclic pain with menses
Dyspareunia
Pelvic inflammatory disease (N73.9)
▶
Cervical motion tenderness
Fever
Herpes simplex proctitis
▶
Vesicles
Ulcers
Neuropathic pelvic pain
▶
Pudendal neuralgia
Coccygodynia
Past Medical History
Relevant baseline conditions
Prior history
▶
Prior hemorrhoids
Prior fissure
Prior abscess
Prior fistula
Inflammatory bowel disease
Colorectal polyps
Prior colorectal cancer
Prior pelvic radiation
Prior anorectal surgery
Prior colonoscopy date
Prior GI bleeding
Baseline function
Functional baseline
▶
Baseline continence
Baseline mobility
Baseline pain disorders
Physical Exam
Initial assessment
General and vitals
▶
Appearance
▶
Toxic
Diaphoretic
Vital signs pattern
▶
Fever pattern
Tachycardia pattern
Hypotension pattern
Abdominal exam
Abdomen
▶
Distension
Focal tenderness
Guarding
Rebound
Bowel sounds change
Perineal and anorectal exam
Anorectal focused exam
▶
Perianal inspection
▶
Erythema
Induration
Fluctuance
Skin necrosis
Bullae
Crepitus
External hemorrhoid
Thrombosis appearance
Anal fissure visible
Sentinel pile
Perianal fistula opening
Discharge
Purulent
Blood
Digital rectal exam limitations
▶
Avoid if severe pain
Avoid if suspected acute fissure severe spasm
Digital rectal exam findings
▶
Mass
Tenderness focal
Boggy fullness
Stool impaction
Blood on glove
Sphincter tone
GU and pelvic exam
Adjacent systems
▶
External genital inspection
▶
Ulcers
Vesicles
Pelvic exam if indicated
▶
Cervical motion tenderness
Vaginal discharge
Neuro exam
Neuro red flags
▶
Lower extremity strength
Sensation saddle region
Reflexes
Anal wink
Lab Studies
Core labs when indicated
Laboratory evaluation
▶
CBC
▶
Leukocytosis sepsis context
Anemia bleeding context
BMP
▶
Renal function for contrast planning
Electrolyte derangements dehydration context
Lactate
▶
Sepsis risk stratification
Tissue hypoperfusion concern
CRP
▶
Inflammatory process support
IBD flare support
Coagulation studies
▶
Warfarin use
Liver disease concern
Type and screen
▶
Significant bleeding concern
Infection and stool testing
Infection evaluation
▶
Blood cultures
▶
Sepsis physiology
Immunocompromised
Stool studies
▶
C difficile testing if recent antibiotics
Enteric pathogen PCR if severe diarrhea
STI testing when indicated
STI evaluation
▶
HIV testing local protocol dependent
Syphilis serology
Gonorrhea NAAT
Chlamydia NAAT
Rectal swab NAAT when relevant
Imaging
Scoring Systems
Imaging decision support
▶
CT escalation decision logic
▶
Suspected deep space infection
Sepsis physiology
Immunocompromised state
Fournier risk scoring adjunct
▶
LRINEC score local protocol dependent
Limitation
▶
Low sensitivity for necrotizing infection
Do not delay surgery for score calculation
MRI
MRI pelvis
▶
Indications
▶
Perianal fistula mapping
Crohn perianal disease extent
Contraindications
▶
Non compatible implanted device
Severe claustrophobia without plan
Pearls
▶
Best soft tissue delineation for fistula
Not first line in unstable patient
CT
CT abdomen pelvis
▶
Indications
▶
Perirectal abscess suspected without clear superficial source
Fournier gangrene concern
Severe pain with systemic features
Peritonitis concern
Protocol considerations
▶
IV contrast if renal function permits
Non contrast if contrast contraindicated
Pearls
▶
Gas in soft tissues supports necrotizing infection
Abscess location guides drainage approach
Pitfalls
▶
Early necrotizing infection may have minimal CT findings
Clinical suspicion overrides reassuring imaging
Ultrasound
Ultrasound and POCUS
▶
Perineal soft tissue ultrasound
▶
Superficial abscess identification
Cellulitis cobblestoning pattern
Bladder ultrasound
▶
Urinary retention assessment
Post void residual estimation
Pitfalls
▶
Deep perirectal collections may be missed
Pain limits probe tolerance
Special Tests
Bedside diagnostics
Targeted bedside tests
▶
Anoscopy if tolerated
▶
Internal hemorrhoid visualization
Fissure confirmation
Proctoscopy if indicated
▶
Proctitis evaluation
Bleeding source visualization
Stool guaiac limitation
▶
Not helpful with visible blood
False positives dietary exposures
Procedural diagnostics
Procedural adjuncts
▶
Perianal abscess needle aspiration rarely definitive
Surgical exploration threshold
▶
Fournier gangrene concern
Rapid progression
ECG
Indications in rectal pain presentations
ECG use cases
▶
Sepsis with tachycardia
Significant bleeding with tachycardia
Older age with comorbidity and hypotension
Assessment
Problem representation
Working diagnosis framing
▶
Anal fissure likely
▶
Pain with bowel movement
Bright red blood
Thrombosed external hemorrhoid likely
▶
Acute tender perianal nodule
Severe focal pain
Abscess possible
▶
Constant pain
Fever pattern
Fluctuance
Proctitis possible
▶
Tenesmus
Discharge
STI exposure
Severity and risk stratification
Risk modifiers
▶
Immunocompromised state
Diabetes mellitus (E11.9)
Anticoagulation use
Systemic toxicity
Inability to tolerate exam
Inability to tolerate oral intake
Plan
First 5 minutes
Immediate priorities
▶
Monitoring
▶
Continuous pulse oximetry if systemic illness
Cardiac monitor if hypotension or tachycardia
IV access
▶
Two large bore IV if bleeding concern
One IV if analgesia and fluids needed
Fluids
▶
Crystalloid bolus 500 mL to 1000 mL if hypotension
Reassess after each bolus
Analgesia early
▶
Acetaminophen PO 1000 mg once
Ketorolac IV 15 mg once
Avoid NSAID if bleeding risk
Morphine IV 2 mg
Reassess every 10 minutes
Sepsis pathway if indicated
▶
Broad spectrum antibiotics within 60 minutes local protocol dependent
Lactate
Diagnostic sequencing
Diagnostic plan
▶
Focused anorectal exam after analgesia
CBC if bleeding concern
CT abdomen pelvis if deep infection concern
STI testing if proctitis risk
Therapeutic management by diagnosis
Anal fissure management
▶
Stool softening
▶
Polyethylene glycol 17 g PO daily
Titrate to soft stool
Topical analgesia
▶
Lidocaine 2 to 5 percent topical small amount up to 3 times daily
Avoid excessive dosing
Sphincter relaxation topical
▶
Nitroglycerin 0.2 to 0.4 percent ointment small amount twice daily
Headache risk
Hypotension risk
Avoid with PDE5 inhibitors recent use
Diltiazem 2 percent topical small amount twice daily
Local compounding often required
Warm sitz baths
▶
10 to 15 minutes
2 to 3 times daily
Thrombosed external hemorrhoid management
▶
Symptom duration decision
▶
Less than 72 hours
Consider excision under local anesthesia if severe pain
Local protocol dependent
Greater than 72 hours
Conservative management preferred
Conservative regimen
▶
Acetaminophen scheduled
NSAID if safe
Topical lidocaine
Stool softener
Hemorrhoids internal management
▶
Constipation management
▶
Fiber supplement
Polyethylene glycol 17 g PO daily
Topical steroid short course
▶
Hydrocortisone topical limited 7 days
Avoid prolonged use
Ongoing bleeding referral
▶
Outpatient GI or colorectal surgery
Colonoscopy consideration age based
Perianal abscess management
▶
Drainage
▶
I and D for superficial fluctuant abscess
Analgesia and local anesthesia
Antibiotics indications
▶
Systemic toxicity
Extensive cellulitis
Immunocompromised
Diabetes mellitus (E11.9)
Valvular heart disease high risk local protocol dependent
Antibiotic options
▶
Amoxicillin clavulanate PO 875 mg twice daily
TMP SMX PO 1 DS tablet twice daily
Add metronidazole PO 500 mg twice daily
Penicillin allergy alternatives local protocol dependent
Deep abscess concern
▶
CT abdomen pelvis
Colorectal surgery consult
Fournier gangrene management
▶
Immediate actions
▶
Emergent surgical consult
Broad spectrum IV antibiotics
Piperacillin tazobactam IV 4.5 g every 6 hours
Add vancomycin IV dosing by weight and renal function local protocol dependent
Add clindamycin IV 900 mg every 8 hours toxin suppression
Do not delay OR for imaging if high suspicion
Infectious proctitis management
▶
Supportive and testing first
▶
Rectal NAAT for gonorrhea
Rectal NAAT for chlamydia
Empiric therapy criteria
▶
Severe symptoms with high STI risk
Awaiting results with unreliable follow up
Local protocol dependent
Example empiric regimen
▶
Ceftriaxone IM 500 mg once
Doxycycline PO 100 mg twice daily 7 days
If lymphogranuloma venereum concern
Extend doxycycline to 21 days local protocol dependent
Herpes proctitis regimen
▶
Acyclovir PO 400 mg three times daily 7 to 10 days
Valacyclovir PO 1000 mg twice daily 7 to 10 days
Reassessment loop
Reassessment triggers
▶
Pain reassess every 30 to 60 minutes
Vital signs reassess after interventions
New fever triggers sepsis workup expansion
Worsening perineal findings triggers surgical escalation
Disposition
Level of care criteria
Disposition decision
▶
ICU or resuscitation level care
▶
Persistent hypotension after fluids
Lactate elevation with shock
Necrotizing infection concern
Inpatient admission
▶
Deep perirectal abscess requiring drainage
Sepsis requiring IV antibiotics
Uncontrolled pain requiring parenteral opioids
Significant bleeding with anemia
Observation pathway
▶
Diagnostic uncertainty requiring serial exams
Pending imaging with pain control needs
Discharge criteria
▶
Stable vitals
Pain controlled with oral regimen
No deep infection concern
Reliable follow up
Clear return precautions
Follow up timing
Copy
Follow up planning
▶
Colorectal surgery follow up 2 to 7 days for abscess drainage check
Primary care follow up 1 to 2 weeks constipation and hemorrhoids
GI follow up for persistent bleeding
Discharge Instructions
Copy discharge instructions
Copy
Diagnosis summary
▶
Rectal pain most consistent with benign anorectal condition
Serious causes were checked based on your symptoms and exam
Medications
▶
Acetaminophen as directed on label
Avoid NSAIDs if you have bleeding or are on blood thinners
Stool softener as prescribed
Topical medicine as prescribed
Home care
▶
Warm sitz baths 10 to 15 minutes 2 to 3 times daily
Drink fluids to keep urine light yellow
Aim for soft stools
Avoid straining
Follow up
▶
Follow up with your doctor within 1 week
Follow up sooner if symptoms are not improving in 48 hours
Return to the ER now for
▶
Fever
Increasing redness or swelling around the anus or genitals
Severe worsening pain
New trouble urinating
Fainting
Large amount of rectal bleeding
New severe belly pain
References
Guidelines and evidence
Core references
▶
American Society of Colon and Rectal Surgeons clinical practice guidelines for hemorrhoids
American Society of Colon and Rectal Surgeons clinical practice guidelines for anal fissure
Infectious Diseases Society of America skin and soft tissue infection guideline for necrotizing infections
CDC sexually transmitted infections treatment guidelines 2021
Surviving Sepsis Campaign guidelines 2021
SymptomDx is an educational tool for medical professionals. It does not replace clinical judgment. Verify all clinical data and drug dosages with authoritative sources.
← Clinical Approaches
Home
Clinical Approaches
Rectal Pain and Anorectal Complaints