Patients commonly present to the emergency department with anorectal complaints. Most of these complaints are benign and can be managed conservatively; however, there are a few anorectal emergencies that clinicians must be aware of in order to prevent further complications. The history and physical examination are especially important so that critical disorders can be recognized and specific treatment plans can be determined. It is important to maintain a broad differential diagnosis of anorectal disease and to distinguish benign from serious processes.
Thorough history and physical can help distinguish between different types of anorectal complaints.
Most anorectal complaints can be managed conservatively, but it is imperative to know when to consult surgeons.
The most common anorectal complaints that present to the emergency department are rectal bleeding, rectal mass, and rectal discomfort, which are often caused by hemorrhoids, anal fissures, and anal abscesses.
Patients with anorectal complaints commonly seek medical care in emergency departments (EDs), but they might not be forthcoming with their history because they are embarrassed. Moreover, because of the sensitive nature of the complaint, patients tend to present later in the course of their illness. However, physicians with an awareness of patients’ reticence about the condition can elicit important information that facilitates the diagnostic process.
Anorectal conditions can be differentiated based on the presenting symptoms, their onset, frequency, and character, their recurrence, and systemic manifestations. The physical examination requires optimal positioning, adequate visualization, and a digital rectal examination (DRE) followed by anoscopy when clinically indicated. Grucela and colleagues documented that physicians’ diagnostic accuracy with anorectal conditions is about 50%, which emphasizes the need for them to become more familiar with the history and clinical findings associated with various anorectal complaints.
The anorectal area is the transition point from the rectosigmoid portion of the intestines to the skin ( Fig. 1 ). The transition occurs at the dentate line. The first 1 to 2 cm distal to the dentate line constitute the anal canal. Distal to the anal canal is the anal verge, which has the appearance of normal external skin, with hair follicles, glands, and subcutaneous tissue. Proximal to the dentate line, the pleats of the rectum form the rectal ampulla with multiple crypts. Tissues distal and proximal to the dentate line have different embryonic origins and therefore have different blood supplies and innervation. The rectum above the dentate line is supplied by the superior hemorrhoidal artery, which is a branch off the inferior mesenteric artery and drains into the portal system through the internal hemorrhoidal plexus; the area below the dentate line is supplied by the middle and inferior hemorrhoidal arteries and drains into the systemic circulation via the external hemorrhoidal plexus. Tissue proximal to the dentate line is insensate, whereas sensation distal to the dentate line is supplied by the pudendal nerve and pelvic branches of S3 and S4 nerve roots.