HISTORY. Ask the patient to describe the kind of pain and the precise location. Determine if the pain is exacerbated by sitting or coughing. Ask if the patient has experienced rectal itching or pain with sitting, coughing, or defecating. Elicit a history of signs of infection such as fever, chills, nausea, vomiting, malaise, or myalgia. Ask the patient if she or he has experienced constipation, which is a common symptom because of the patient's attempts to avoid pain by preventing defecation.

PHYSICAL EXAMINATION. Inspect the patient's anal region. Note any red or oval swelling close to the anus. Digital examination may reveal a tender induration that bulges into the anal canal in the case of ischiorectal abscess, or a smooth swelling of the upper part of the anal canal or lower rectum in the case of submucous or high intermuscular abscess. Digital examination may reveal a tender mass high in the pelvis, even extending into one of the ischiorectal fossae if the patient has a pelvirectal abscess. Examination of a perianal abscess generally reveals no abnormalities. Examination may not be possible without anesthesia. Note any pruritic drainage or perianal irritation, which are signs of a fistula.

On inspection, the external opening of the fistula is usually visible as a red elevation of granulation tissue with purulent or serosanguinous drainage on compression. Palpate the tract, noting that there is a hardened cordlike structure. Note that superficial perianal abscesses are not uncommon in infants and toddlers who are still in diapers. The abscess appears as a swollen, red, tender mass at the edge of the anus. Infants are often fussy, but may have no other symptoms.

PSYCHOSOCIAL. Patients with perirectal abscesses and fistulas may delay seeking treatment because of embarrassment relating to the location, the odor, or the sight of the lesion. Provide privacy and foster dignity when interacting with these patients. Inform the patient of every step of the procedure. Provide comfort during the examination.

Diagnostic Highlights

Abnormality with

Test Normal Result Condition Explanation

White blood cell Adult males and females Elevated Infection and inflammation

(WBC) count 4,500-11,000/mL may elevate the WBC count

Other Tests: Barium studies; sigmoidoscopy; colonoscopy; cultures of exudate.

Anorectal Abscess and Fistula 83

Constipation Prescription

Constipation Prescription

Did you ever think feeling angry and irritable could be a symptom of constipation? A horrible fullness and pressing sharp pains against the bladders can’t help but affect your mood. Sometimes you just want everyone to leave you alone and sleep to escape the pain. It is virtually impossible to be constipated and keep a sunny disposition. Follow the steps in this guide to alleviate constipation and lead a happier healthy life.

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