Six features are of diagnostic importance : pain, bleeding, pruritus ani, anal swelling, discharge, abnomalies on defaecation.
A - Pain :
Mode of onset, severity, characteristics, site of timing in relation to defaecation:
- in anitis and papillitis the pain occurs with defaecation,
- it is delayed in cases of fissure-in-ano,
- it is constant in anal suppuration,
it is variable in anorectal neuralgia
B - Bleeding :
It is the presence of revctal bleeding which is important and worrying, rather than its volume, frequency or nature, and which makes the patient take medical advice.
C - Pruritus ani
D - Anal swelling :
Is felt by the patient and may be reducible or irreducible.
E - Discharge :
There may be real pus in cases of fissure or a mucous discharge in haemorrhoids.
F - Abnormalites on defaecation :
Number and characteristics of stools : frequent small motions may suggest diarrhoea but this may be spurious and constipation may in effect be the real problem, with obvious therapeutic implications.
Irritation by laxatives and reccurrent diarrhoea are known to be factors in the aetiology of haemorrhoids and fissures.
It is important to exclude false motions, which amount to the evacuation of some flatus, mucus or a few drops of blood : such features should immediately raise the possibility of a malignant tumour.
The history may thus be very helpful but it is iften disappointing : some patients are not aware of the importance of the questions and give vague and incomplete answers, while others exaggerate their symptoms.
- > External examination
- > Ano-rectal examination
- > Proctoscopy
This may be very informative provided the patient is placed in the right position, i.e. knee-chest, with the anal region brightly illuminated by a projector or by a Clar mirror placed on the forehead.
What can that examination show ?
In many cases :
- an external prolapse of the mucosa or of the mucosa and haemorrhoids, of hypertrophied anal papillae;
- skin tags caused by subcutaneous swelling from old prolapsed haemorrhoids and subsequent changes in the epidermis ;
- dry or wet eczema, often with scratch marks of rhagades;
- the anal folds are sometimes thickened, with the appearances if lichenification and dullness of the perianal skin;
- condylomata acuminata;
- there may also be thrombosed haemorrhoids - one or more blue-back swellings under the skin at the anal margin, which may be raised, and there may be very considerable and painful oedema.
- Fissure-in-ano is an excoriation of the anal mucosa which is concealed to some extent by a sentinel tag ; it differs from cryptitis, which is more superficial and less painful.
Where spasm is present, local anaesthesia is necessary to relax the anus and make it visible.
Anal suppuration can be detected on examination when the anal fistula is open to the exterior : there is a pustule, and there may be several, 3 to 5 cm from the anal margin into which can be introduced a probe.
More rarely there may be :
- multiple suppurative orifices which do not communicate with the anal canal (Verneuil's disease),
- small moist and suppurative condylomata of Crohn'sdisease, sometimess with considerable loss of sunstance,
- syphilitic ulceration, always with inguinal adenitis,
- rarely, tuberculous ulceration.
These lesions require specialist advice, biopsy and laboratory investigations.
Thus the history and external physical examination may lead to the diagnosis of the anal lesion and can exclude classical marginal carcinoma, which presents a cauliflower appearance or as an extensive ulcer with very thick edges. Nevertheless all the clinical forms are possible and a biopsy is without doubt indicated.
There is a very important step but one which is not sufficient in many cases to enable a diagnosis to be made.
It reveals infiltrating and inflammatory lesions but also ans particularly neoplastic lesions.
If proctoscopy cannot be carried out after rectal examination, the dorsal position is to be preferred as it allows the finger to be introducted higher.
This is the crucial examination : every practitioner should have a proctoscope.
Thus, any general practitioner can diagnose anal lesions on the basis of a short history and of easy rectal and proctoscopic examinations. Where this is possible, he can also treat his patient by simple local etd general measures, often with considerable symptomatic relief.