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Emergency Medicine Atlas > Part 1. Regional Anatomy > Chapter 9. Sexually Transmitted Diseases and Anorectal Conditions > Sexually Transmitted Diseases >

Primary Syphilis

Associated Clinical Features

Lesions of primary syphilis generally appear after an incubation period of 2 to 6 weeks, but they may appear up to 3 months after exposure. The patient usually presents with a solitary round to oval painless genital ulcer (Figs. 9.1 and 9.2). However, the ulcer may be slightly painful, and several lesions are sometimes seen. The base of the genital ulcer is dry in males, moist in females; purulent fluid in the base is uncommon. The borders of the ulcer are often indurated. Patients may develop ulcers at any site of inoculation on the body. Bilateral, nontender, nonfluctuant adenopathy is common. Lesions resolve spontaneously in 3 to 12 weeks without treatment as the infection progresses to the secondary stage. Patients with primary syphilis are at risk for concurrent infection with other sexually transmitted diseases.

Figure 9.1

Primary Chancre—Male This dry-based, painless ulcer with indurated borders is typical for a primary chancre in a male patient. (Courtesy of A. Wisdom: Sexually Transmitted Diseases. London: Mosby-Wolfe; 1992.)

Figure 9.2

Primary Chancre—Female A solitary, painless genital chancre with a clean base in a patient with primary syphilis. (Courtesy of the Department of Dermatology, Naval Medical Center, Portsmouth, VA.)

Differential Diagnosis

Behçet's disease, fixed drug eruption, recurrent genital herpes, chancroid, squamous cell carcinoma, and lesions caused by trauma can have a similar appearance.

Emergency Department Treatment and Disposition

Treat with benzathine penicillin G, 2.4 million units IM once. Penicillin-allergic patients should be given doxycycline, 100 mg PO bid for 2 weeks. Other alternatives include tetracycline, 500 mg PO qid for 2 weeks; erythromycin base, 500 mg PO qid for 2 weeks; or ceftriaxone, 250 mg IM once daily for 10 days. An RPR or VDRL should be checked. Partners within the last 90 days should be treated presumptively; partners over the last 90 days should be treated on the basis of their serologic testing results. This is a reportable disease, and appropriate paperwork should be filed.

Clinical Pearls

1. Lesions are usually painless and solitary, but they may be slightly painful; two or three lesions may also be seen.

2. Consider dark-field examination of the lesion to rapidly confirm the diagnosis.

3. Chancres of primary syphilis can occur anywhere on the body at the site of inoculation.

4. Evaluate patients with primary syphilis for concurrent sexually transmitted diseases and treat accordingly.

Secondary Syphilis

Associated Clinical Features

The rash of secondary syphilis often occurs 2 to 10 weeks after resolution of the primary lesions. It begins as a nonpruritic macular rash that evolves into a papulosquamous rash involving primarily the trunk, palms, and soles (Figs. 9.3, 9.4, 9.5). The rash is often annular in shape. Diffuse, painless lymphadenopathy is also seen at this stage. Mucous patches represent mucous membrane involvement of the tongue and buccal mucosa (Fig. 9.6). Condyloma lata (Fig. 9.7) can be seen during this stage, as can patchy alopecia. The manifestations of this stage resolve without treatment in several months.

Figure 9.3

Secondary Syphilis—Trunk Rash on trunk in secondary syphilis. (Courtesy of A. Wisdom: Sexually Transmitted Diseases. London: Mosby-Wolfe; 1992.)

Figure 9.4

Secondary Syphilis—Palms Papulosquamous rash of secondary syphilis. Note the annular appearance of the palmar rash. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.5

Secondary Syphilis—Soles Hyperkeratotic plantar rash in a patient with secondary syphilis. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.6

Mucous Patches Oral involvement in secondary syphilis manifest by mucous patches. These lesions are very infectious, and dark-field examination is often positive for spirochetes. (Courtesy of Morse, Moreland, Thompson: Atlas of Sexually Transmitted Diseases. London: Mosby-Wolfe; 1990.)

Figure 9.7

Condyloma Lata Typical appearance of the verrucous, heaped up lesions of condyloma lata, a manifestation of secondary syphilis. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Differential Diagnosis

The differential diagnosis depends on the site involved:

Rash: Pityriasis rosea, psoriasis, lichen planus, Reiter's syndrome, viral syndrome, allergic rash

Mucous patches: Apthous ulcerations, thrush

Condyloma lata: Condyloma accuminata, squamous cell carcinoma, granuloma inguinale

Emergency Department Treatment and Disposition

Benzathine penicillin G, 2.4 million units IM once; penicillin allergic patients should receive doxycycline, 100 mg PO bid for 2 weeks. RPR or VDRL should be sent and titers followed to determine adequate response to therapy. Suspected and confirmed cases of syphilis must be reported to public health officials.

Clinical Pearls

1. Lesions of secondary syphilis are very infectious. It is prudent to always wear gloves when examining a patient with a rash that may be due to secondary syphilis.

2. Consider using dark-field examination of scrapings of the rash, mucous patches, and condyloma lata to make a rapid diagnosis.

3. Patients should be warned about the potential development of the Jarish-Herxheimer reaction after they are treated. This syndrome, characterized by fever, headache, malaise, and myalgias, occurs within 24 h of treatment and is caused by massive release of pyrogens by the dying spirochetes.

Gonorrhea

Associated Clinical Features

Gonorrhea often becomes manifest after a short incubation period of 2 to 5 days. In men, urethritis is characterized by purulent, usually copious urethral discharge (Fig. 9.8) with dysuria; however, up to 10% of men are asymptomatic. Women may also develop urethritis (Fig. 9.9) and complain of dysuria. Cervicitis is often asymptomatic. If symptomatic, women may complain of increased vaginal discharge or vaginal spotting, particularly after intercourse. On speculum examination, the cervix is friable, with a mucopurulent endocervical exudate (Fig. 9.10). Patients with gonococcal conjunctivitis have chemosis and copious purulent exudate (Fig. 9.11); untreated, these patients can develop endophthalmitis and perforation of the globe. Untreated gonorrhea may disseminate and more commonly does so in women. Disseminated gonococcal infection (DGI) typically presents with a monoarticular septic arthritis usually involving the knees, ankles, elbows, or wrists. Skin lesions are necrotic pustules on an erythematous base; they may ulcerate and are more commonly found on the distal extremities (Figs. 9.12, 9.13).

Figure 9.8

Male Urethritis Purulent, copious urethral discharge in a patient with gonococcal urethritis. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.9

Female Urethritis Gonococcal urethritis in a female patient. Note the purulent urethral discharge. (Courtesy of Morse, Moreland, Thompson: Atlas of Sexually Transmitted Diseases. London: Mosby-Wolfe; 1990.)

Figure 9.10

Cervicitis Endocervical purulent exudate in an asymptomatic patient with gonococcal cervicitis. The cervix is very friable. (Courtesy of King K. Holmes, MD, from H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.11

Conjunctivitis Chemotic conjunctiva and copious purulent exudate in a patient with gonococcal conjunctivitis. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.12

Skin Lesions Small pustules with hemorrhage suggestive of the skin lesions of disseminated gonococcal infection. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.13

Bartholin's Cyst Enlarged, fluctuant, tender Bartholin's abscess of the labia, usually but not always a result of gonorrhea. (Courtesy of A. Wisdom: Sexually Transmitted Diseases. London: Mosby-Wolfe; 1992.)

Differential Diagnosis

The differential diagnosis depends on the site involved:

Urethritis and cervicitis: Chlamydia, Mycoplasma, Ureaplasma

Conjunctivitis: Bacterial conjunctivitis, chemical conjunctivitis

Arthritis: Septic arthritis, rheumatic fever, hepatitis B prodrome, immune complex disease, Reiter's syndrome, systemic lupus erythematosus

Skin lesions: Folliculitis, subacute bacterial endocarditis (septic emboli)

Emergency Department Treatment and Disposition

Treatment is dependent on the site of infection:

Urethritis and cervicitis: Ceftriaxone, 125 mg IM once; cefixime, 400 mg PO once; ciprofloxacin, 500 mg PO once; ofloxacin, 400 mg PO once.

Conjunctivitis: Ceftriaxone 1 g IM once; eye irrigation.

Disseminated gonococcal infection: Ceftriaxone, 1 g IV or IM daily for 7 to 10 days; may treat with 1 to 2 days of IM ceftriaxone and then change to cefixime, 400 mg PO bid, or ciprofloxacin, 500 mg PO bid, to complete a 7- to 10-day course. Sexual partners should be notified and treated. Gonorrhea is a reportable disease.

Clinical Pearls

1. Patients with gonorrhea need to be treated for concurrent infection with Chlamydia. Coinfection with these organisms is seen in 30% of men with urethritis and 50% of women with cervicitis.

2. Gonococcal arthritis is the most common cause of monoarticular arthritis in young, sexually active patients.

3. Suspect gonococcal conjunctivitis in patients with copious eye discharge and chemosis.

4. Cultures are the gold standard for confirming the diagnosis of gonorrhea. Selective media should be used when specimens are obtained from the cervix, pharynx, urethra, or rectum. Nonselective medium (blood agar) should be used in culturing joint fluid, blood, or cerebrospinal fluid.

Chlamydial Infection

Associated Clinical Features

After an incubation period of 1 to 3 weeks, males with urethritis may present with a thin, often clear urethral discharge and dysuria (Fig. 9.14). Up to 10% of these men may be asymptomatic. Women may also develop urethritis, which may only cause dysuria and be misdiagnosed as a urinary tract infection. Cervicitis in women (Fig. 9.15) is almost always asymptomatic. Women may develop pelvic inflammatory disease with upper genital tract infection. Men may develop epididymitis.

Figure 9.14

Male Urethritis Thin urethral discharge of chlamydial urethritis. (Courtesy of Walter Stamm, MD, from H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.15

Cervicitis Mucopurulent cervicitis from chlamydial infection. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Differential Diagnosis

For urethritis and cervicitis, Neisseria gonorrhoeae, Mycoplasma, and Ureaplasma should be considered.

Emergency Department Treatment and Disposition

The preferred treatment consists of azithromycin, 1 g PO once, or doxycycline 100 mg PO bid for 7 days. Alternatives include ofloxacin, 500 mg PO bid for 7 days. Pregnant women should receive erythromycin base, 500 mg, or erythromycin ethylsuccinate 800 mg PO qid for 7 days. Partners should be examined and treated appropriately.

Clinical Pearls

1. Chlamydial infection often accompanies gonococcal infection, and patients being treated for gonorrhea should also be treated for chlamydial infection.

2. Women with chlamydial infections may be completely asymptomatic for long periods of time.

3. Consider syphilis serologic testing and HIV testing in patients presenting with sexually transmitted diseases.

Lymphogranuloma Venereum

Associated Clinical Features

Lymphogranuloma venereum (LGV) is caused by a serotype of Chlamydia trachomatis and is primarily a disease of lymphatic tissue. Initially, LGV is often a painless genital ulceration that is not noticed by the patient more than 90% of the time. Patients often present with painful, nonfluctuant inguinal adenopathy, which is often but not always unilateral (Fig. 9.16). Lymph-adenopathy may lie above and below the inguinal ligament, causing the "groove sign" suggestive of this diagnosis. The lesion of lymphadenopathy may spontaneously open into draining sinus tracts to the skin.

Figure 9.16

Lymphogranuloma Venereum Unilateral left lymphadenopathy in a patient with lymphogranuloma venereum. (Courtesy of Lawrence B. Stack, MD.)

Differential Diagnosis

Chancroid, granuloma inguinale, lymphoma, pyogenic or mycobacterial infection, syphilis, and cat-scratch disease may have a similar appearance.

Emergency Department Treatment and Disposition

Doxycycline, 100 mg PO bid for 3 weeks. Rarely, patients may need needle aspiration of the lymph nodes if they become fluctuant. Serologic testing is needed to confirm the diagnosis.

Clinical Pearls

1. Patients rarely note the evanescent ulcer associated with LGV.

2. The lymphadenopathy of LGV progresses over several weeks.

3. Treatment for LGV requires 3 weeks of therapy for a cure.

Genital Herpes

Associated Clinical Features

Herpes genitalis presents in several ways: symptomatic primary infection, first-episode nonprimary infection, and recurrent infection. Symptomatic primary infection occurs when the patient develops symptoms upon first acquiring the virus. Some patients may be asymptomatic when primarily infected with the virus, however, and present at a later time with their first symptomatic episode of nonprimary genital herpes. Patients with either symptomatic primary infection or first-episode nonprimary infection may develop recurrences.

Symptomatic primary genital herpes is characterized by multiple vesicles that quickly ulcerate into shallow, painful ulcers (Figs. 9.17, 9.18). The ulcers may coalesce. The lesions are accompanied by a viral syndrome with low-grade fever and myalgias. Up to 10% of patients may develop aseptic meningitis. Women may develop sacral autonomic dysfunction and require urinary catheterization because of urinary retention. The lesions last up to 3 weeks and heal without scarring.

Figure 9.17

Primary Lesions—Female Multiple coalescing superficial ulcerations of primary genital herpes. (Courtesy of Lawrence B. Stack, MD.)

Figure 9.18

Primary Lesions—Male Multiple genital vesicles of primary genital herpes. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

First-episode nonprimary genital herpes and recurrent genital herpes are less dramatic (Fig. 9.19). Patients with first-episode nonprimary genital herpes do not have systemic symptoms, have solitary to several painful lesions, and resolve their symptoms in 1 to 2 weeks. Recurrences of genital herpes are often heralded by a warning prodrome of tingling or numbness in the perineal area. Vesicles and their subsequent ulcers are often solitary. The duration of symptoms is often several days and usually less than a week.

Figure 9.19

Recurrent Lesions—Female Solitary, minimally painful lesion of recurrent genital herpes. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Differential Diagnosis

Pustular psoriasis, chancroid, erythema multiforme, fixed drug eruption, Behçet's disease, Stevens-Johnson syndrome, pyoderma gangrenosum, syphilis, and pyodermic infection may have a similar appearance.

Emergency Department Treatment and Disposition

Primary genital herpes: Acyclovir, 200 mg PO five times daily for 7 to 10 days or until symptoms resolve; 400 mg PO tid may be substituted for patient convenience.

Recurrent genital herpes: Acyclovir, 200 mg PO five times daily; 400 mg PO tid for 5 to 7 days; or Famciclovir, 125 mg PO bid for 5 days.

Clinical Pearls

1. Women with genital herpes must be counseled to inform their obstetrician of this history of herpes when they become pregnant.

2. Genital herpes is the most common cause of ulcerating genital lesions.

3. Patients may initially present with full-blown primary genital herpes symptoms or may have their first clinical presentation as a recurrence of an asymptomatically acquired infection (Fig. 9.20).

Figure 9.20

Herpes Simplex Virus—Cervix Erosive ulcerations of the cervix in a patient with genital herpes infection. This patient may be completely asymptomatic and may transmit the disease. (Courtesy of A. Wisdom: Sexually Transmitted Diseases. London: Mosby-Wolfe; 1992.)

Chancroid

Associated Clinical Features

Chancroid is caused by Haemophilus ducreyi. After an incubation period of 2 to 10 days, this disease presents with multiple, painful, nonindurated genital ulcerations that are often deep and undermined and may have a purulent base (Fig. 9.21). Inguinal adenopathy may develop and becomes fluctuant, large, and painful (Fig. 9.22). Infected lymph nodes may rupture spontaneously. Systemic symptoms are uncommon.

Figure 9.21

Chancroid Lesions Multiple painful, deep ulcerations of chancroid. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.22

Chancroid Lesions and Inguinal Nodes Chancroid lesions with an enlarged lymph node. On examination, this node is tender and fluctuant. (Courtesy of H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Differential Diagnosis

Lymphogranuloma venereum, granuloma inguinale, herpes simplex virus, and syphilis should be considered.

Emergency Department Treatment and Disposition

Ceftriaxone, 250 mg IM once, or azithromycin, 1 g PO once. Alternatives include amoxicillin and clavulanic acid, 500 mg and 125 mg PO tid for 7 days or ciprofloxacin, 500 mg PO bid for 3 days. Large, fluctuant nodes should be aspirated to prevent rupture; incision and drainage should be avoided to prevent development of chronic draining sinus tracts. Partners should be notified of exposure to the disease.

Clinical Pearls

1. Chancroid is usually found in high-risk populations: drug-abusing, inner-city.

2. Chancroid is a diagnosis of exclusion, as culturing H. ducreyi requires a special medium not readily available. Genital herpes and syphilis must be ruled out.

3. The lymphadenopathy of chancroid is often very tender and fluctuant.

4. Chancroid lesions are very tender and usually multiple.

Pediculosis

Associated Clinical Features

Pediculosis can be caused by either the body louse or the crab louse. Body lice (Fig. 17.21) are not sexually transmitted and tend to cluster around the waist, shoulders, axillae, neck, and head. They are extremely itchy; patients may present with excoriations and intense pruritus. The lice are very small and may not be easily seen. The larval form of the louse, the nit, may be mistaken for dandruff in the hair. Unlike dandruff, however, the nits are extremely adherent to the hair shaft and cannot be brushed out of the hair. The adult lice and their eggs are often found in the seams of clothing.

Pubic infestation is caused by Phthirus pubis, the crab louse (Figs. 9.23, 21.20). Patients may present with intense itching in the pubic area; however, as many as half of patients with this infestation may be asymptomatic. Patients may notice the lice or may note tiny rust-colored spots on their underwear, which represent bleeding from the sites of louse bites. Nits may be found at the base of pubic hairs and hatch in 5 to 10 days.

Figure 9.23

Pediculosis Pubis—on Hairs Phthirus pubis, or the crab louse, in the pubic hair of a patient complaining of itching. Note also the nits attached to the hairs. (Courtesy of Morse, Moreland, Thompson: Atlas of Sexually Transmitted Diseases. London: Mosby-Wolfe; 1990.)

Differential Diagnosis

Tinea, contact dermatitis, scabies, and heat rash may have a similar appearance.

Emergency Department Treatment and Disposition

Lindane shampoo (Kevell) should be lathered into the pubic, perineal, and perianal hair, or lindane lotion applied in the affected areas and left on for 10 min and rinsed off. Synergized pyrethrins (RID), or synthetic pyrethrins (NIX, Elmite), may also be used. Since lindane may be toxic, pyrethrins are preferred in pregnant women and children. Treatment should be repeated in 1 week to treat any nits that may have hatched. Clothing worn or linen used in the preceding 24 h should be washed. Mechanical removal of nits attached to hairs should be attempted. Petroleum jelly or any bland ophthalmic ointment can be applied to the eyelashes twice daily for a week to treat infestation of the eyelashes (Fig. 9.24). Sexual contacts should be examined.

Figure 9.24

Pediculosis Pubis—on Eyelashes Phthirus pubis lice noted in the eyelashes. (Courtesy of Spalton, Hitchings, Hunter: Atlas of Clinical Ophthalmology, 2d ed. London: Mosby–Year Book Europe; 1994.)

Clinical Pearls

1. Nits are easier to find on examination than are mature lice; the average number of lice in an infestation is only 10.

2. Patients with pediculosis pubis should be considered at risk for other sexually transmitted diseases and examined.

3. Lindane shampoo or lotion should not be used in infants under 1 year of age or in pregnant women.

Condyloma Acuminata (Genital Warts)

Associated Clinical Features

Caused by human papillomavirus (HPV), these flesh-colored lesions may be flat, sessile, or pedunculated (Figs. 9.25, 9.26). They often have a cauliflowerlike appearance and are usually asymptomatic but may be seen or felt by patients or their sexual partners. They range in size from 1 to 4 mm to masses that may be several centimeters large (giant warts, Figs. 9.27, 9.28).

Figure 9.25

Genital Warts—Female Verrucous lesions of the posterior fourchette in a patient with condyloma acuminata. (Used with permission from H. Hunter Handsfield: Atlas of Sexually Transmitted Diseases. New York: McGraw-Hill; 1992.)

Figure 9.26

Genital Warts—Male Typical appearance of condyloma acuminata of the glans penis. (Courtesy of Morse, Moreland, Thompson: Atlas of Sexually Transmitted Diseases. London: Mosby-Wolfe; 1990.)

Figure 9.27

Giant Warts—Female Giant warts of a female patient with extensive condyloma acuminata. (Courtesy of Morse, Moreland, Thompson: Atlas of Sexually Transmitted Diseases. London: Mosby-Wolfe; 1990.)

Figure 9.28

Giant Warts—Male Giant warts in a male patient with extensive condyloma acuminata. (Courtesy of A. Wisdom: Sexually Transmitted Diseases. London: Mosby-Wolfe; 1992.)

Differential Diagnosis

Condyloma lata due to secondary syphilis is the primary alternative diagnosis (Fig. 9.7). Bowen's disease, molluscum contagiosum, and carcinoma may have a similar appearance.

Emergency Department Treatment and Disposition

Local caustic agents (e.g., podophyllin) are used to treat the lesions; multiple treatment is often needed, and recurrence is common. Other therapies include cryotherapy, electrocautery, and trichloracetic acid. Laser therapy or surgery may be needed in cases of giant warts.

Clinical Pearls

1. Evidence suggests that HPV is linked with increased risk of cervical cancer.

2. Women with genital warts need to have a Pap smear to rule out coexisting carcinoma in situ.

3. Large lesions should be biopsied to rule out cancer.

4. Patients should be advised that it may take several to many visits to completely eradicate the condyloma.

5. In cases where the diagnosis is not obvious, rule out condyloma lata (secondary syphilis) by sending serologic studies.

Anal Fissure

Associated Clinical Features

An anal fissure is a longitudinal tear in the skin of the anal canal and usually extends from the dentate line to the anal verge. Fissures are thought to be caused by the passage of hard or large stools with constipation, but they may also be seen with diarrhea. The fissures are typically a few millimeters wide and occur in the posterior midline (Fig. 9.29), but they can occur elsewhere. An anal fissure that is off the midline may have a secondary cause, such as inflammatory bowel disease or sexually transmitted infection. Although often seen in infants, this condition is found mostly in young and middle-aged adults. Patients present with the complaint of intense sharp, burning pain during and after bowel movements. They may also note bright red blood at the time or shortly after the passage of stool. Gentle examination with separation of the buttocks usually provides good visualization (Fig. 9.29). Anoscopy should be performed, if possible.

Figure 9.29

Anal Fissure A typical anal fissure located in the posterior midline. (Courtesy of Paul J. Kovalcik, MD.)

Differential Diagnosis

The diagnosis of inflammatory bowel disease, ulcerative colitis, or Crohn's disease should be considered, particularly if the fissure is atypical. Anal fissures may be the result of a sexually transmitted disease such as Chlamydia, gonorrhea, herpes, and syphilis. Tuberculosis, anal neoplasms, and sickle cell disease can also present as an anal fissure. An anal abscess and thrombosed hemorrhoids may cause similar symptoms but can usually be ruled out on physical examination.

Emergency Department Treatment and Disposition

Acute treatment of anal fissures consists of anal hygiene, bulk fiber diet supplements to soften stools, warm sitz baths, and topical anesthetics. Oral pain medication and muscle relaxants such as diazepam may be required in certain patients.

Clinical Pearls

1. Pain and involuntary sphincter spasm may preclude a routine digital or anoscopic examination and require an examination under anesthesia.

2. A proctoscopic examination should be done at some point to rule out secondary causes.

3. Most anal fissures heal spontaneously, but refractory cases may require surgical repair.

Perianal-Perirectal Abscesses

Associated Clinical Features

The perianal abscess is the most common anorectal abscess. It is associated with pain in the anal area that is exacerbated by bowel movements, straining, coughing, or palpation. On examination, a fluctuant and possibly erythematous mass is found at the perianal region (Fig. 9.30). Perianal abscesses are usually fairly superficial and easy to drain with local anesthesia. The patient may notice swelling or a pressure sensation. Perirectal abscesses tend to be more complex and are named according to the involved space: ischiorectal, intersphincteric, or supralevator (Fig. 9.31). These are fluctuant masses that are usually palpable along the rectal wall. Patients may complain of pain, fever, and mucous or bloody discharge with bowel movement.

Figure 9.30

Perianal Abscess Swelling and erythema around the anus consistent with a perianal abscess. (Courtesy of the American Society of Colon and Rectal Surgeons.)

Figure 9.31

Perianal-Perirectal Abscesses The anatomy of perianal and perirectal abscesses is illustrated. Also shown are anal fissure and internal and external hemorrhoids.

Differential Diagnosis

Crohn's disease should be considered, because 36% of Crohn's patients have a perianal abscess at the presentation of their disease. An underlying process may exist, such as diabetes mellitus, leukemia, or other malignancy.

Emergency Department Treatment and Disposition

Incision and drainage of perianal abscesses should be performed with a small radial or cruciate incision lateral to the external sphincter. For an uncomplicated abscess, this can be accomplished under local anesthesia. The cavity should be cleared of loculations and then loosely packed with iodoform gauze, which should be removed in 24 to 48 h. All patients require outpatient follow-up. Antibiotic therapy is not indicated unless there is underlying disease affecting the patient's immunologic function or the patient appears septic. Surgical consultation should be obtained for treatment of perirectal abscesses under anesthesia.

Clinical Pearls

1. Surgical consultation and treatment may be required in the patient with a large or complicated perianal abscess or where adequate analgesia cannot be obtained.

2. Consider admission for debilitated, elderly, febrile, obese, or otherwise ill-appearing patients.

3. All patients warrant follow-up referral due to the high incidence of fistulae with anorectal abscesses.

Internal-External Hemorrhoids

Associated Clinical Features

External hemorrhoids result from the dilatation of the venules of the inferior hemorrhoidal plexus below the dentate line. They have a covering of skin, or anoderm, versus internal hemorrhoids, which have a mucosal covering. Hemorrhoids commonly present with an episode of rectal bleeding of bright red blood after defecation. This results from the passage of the fecal mass over the thin-walled venules, causing abrasions and bleeding. Symptoms from external hemorrhoids include complaints of swelling and burning rectal pain. Numerous associated factors exist, such as constipation, family history, pregnancy, portal hypertension, or increased intraabdominal pressure. Hemorrhoids are commonly found at three anatomic locations: right anterior, right posterior, and left lateral positions (Fig. 9.32). A thrombosed external hemorrhoid contains intravascular clots and causes exquisite pain the first 48 h.

Figure 9.32

External Hemorrhoids Multiple engorged external hemorrhoids are seen in all quadrants. (Courtesy of the American Society of Colon and Rectal Surgeons.)

Internal hemorrhoids (Figs. 9.31, 9.33) present with painless rectal bleeding or possibly the sensation of prolapse. They are graded according to the degree of prolapse, where the first degree is identifiable at the dentate line and the fourth degree shows irreducible prolapse through the anus. Internal hemorrhoids are not typically painful, whereas external hemorrhoids do cause pain.

Figure 9.33

Internal Hemorrhoids Internal hemorrhoids are seen in this endoscopic view of the rectum. (Courtesy of Virender K. Sharman, MD.)

Differential Diagnosis

Other diagnoses to consider include infection, perianal or perirectal abscess, inflammatory bowel disease, malignancy, local trauma, herpes or other sexually transmitted infection, rectal polyp, or rectal prolapse.

Emergency Department Treatment and Disposition

In the case of severe bleeding, fluid resuscitation would need to be instituted and the bleeding vessel located, clamped, and ligated. The treatment for less severe cases warrants more conservative therapy, including increased dietary fiber, increased fluid intake, hot sitz baths, bed rest, and nonnarcotic pain medication. Advanced cases may require surgical consultation and treatment. ED treatment of thrombosed external hemorrhoids includes an elliptical excision and extrusion of the clot under local anesthesia.

Clinical Pearls

1. Many patients with any anorectal problem complain of hemorrhoids. Therefore, careful examination and consideration of the differential diagnosis should be undertaken with each patient.

2. Having the patient strain during the examination may reveal bleeding or prolapse that might otherwise go unnoticed.

3. Hemorrhoids are a rare cause of anorectal pruritus.

Prolapsed Rectum

Associated Clinical Features

Rectal prolapse occurs when anorectal tissue slides through the anal orifice; it can include mucosa or a full-thickness layer. This is due to several anatomic features, including laxity of the pelvic floor, weak anal sphincters, and lack of mesorectal fixation. Patients complain of bleeding, mucous discharge, rectal pressure, or a mass (Fig. 9.34). Problems with fecal incontinence, constipation, and rectal ulceration are common as well. Prolapse may be associated with an increased familial incidence, chronic cough, dysentery, or parasitic infection.

Figure 9.34

Prolapsed Rectum The rectum is completely prolapsed in this elderly patient. (Courtesy of Alan B. Storrow, MD.)

Differential Diagnosis

Other diagnoses to consider include foreign body, tumor, perianal or perirectal abscess, rectal polyp, or engorged external hemorrhoids.

Emergency Department Treatment and Disposition

Usually reduction is possible with gentle manual pressure. However, if this cannot be accomplished, surgical consultation and admission are needed. Surgical treatment is also indicated with a complete prolapse. All patients should undergo an anoscopic and sigmoidoscopic examination at some point; if rectal bleeding is a problem, full colonic evaluation should be completed.

Clinical Pearls

1. This is commonly seen in children with cystic fibrosis (22%); therefore, all children with rectal prolapse should have a sweat chloride test.

2. Examination of rectal prolapse reveals concentric mucosal rings and a sulcus between the anal canal and the rectum, whereas prolapsed hemorrhoids are separated by radial grooves and the sulcus is absent.

3. To confirm the diagnosis, prolapse may be reproduced by having the patient bear down.

Pilonidal Abscess

Associated Clinical Features

Pilonidal abscesses are typically seen at or just superior to the gluteal fold (Fig. 9.35) and are more common in teenage and young adult males. Patients complain of localized pain, swelling, and drainage but usually do not have systemic symptoms. The abscess begins with the formation of a small opening in the skin that develops into a cystic structure involving surrounding hairs. This opening is occluded by hair or keratin, creating a closed space that does not allow drainage. The acute abscess contains mixed organisms including Staphylococcus aureus and Streptococcus, but anaerobes and gram-negative organisms may also be present.

Figure 9.35

Pilonidal Abscess Redness, fluctuance, and tenderness in the gluteal cleft seen with a pilonidal abscess. (Courtesy of Louis La Vopa, MD.)

Differential Diagnosis

Evidence of cellulitis in the sacrococcygeal area may result from a simple abscess or furuncle. However, other causes should be considered, such as anal fistulae, hidradenitis, inflammatory bowel disease, or tuberculosis.

Emergency Department Treatment and Disposition

An acutely fluctuant abscess requires incision and drainage under local anesthesia with removal of pus and debris. The patient should be instructed on meticulous wound care and sitz baths. Antibiotic therapy is not indicated unless the patient is immunocompromised. Surgical referral is given, particularly with a chronic or recurrent cyst, which may require surgical excision and closure.

Clinical Pearls

1. Pilonidal abscesses almost always occur in the midline but can have sinus tracts extending off the midline.

2. Pilonidal disease is three times more common in men than in women.

Rectal Foreign Body

Associated Clinical Features

The diagnosis of rectal foreign body is usually made by history and confirmed by digital examination. Most often the foreign body is inserted (Fig. 9.36), but it is possible to have an ingested foreign body trapped in the rectum. The most serious complication of a rectal foreign body is perforation of the rectum or distal colon. The patient must be carefully evaluated for evidence of perforation with x-rays demonstrating free air and clinically for the presentation of an acute abdomen. Perforation above the peritoneal reflection is associated with free air in the abdominal cavity and peritoneal signs. Perforation below the peritoneal reflection presents with more insidious signs of pain and infection in the perianal or perineal region. It is important to determine the size, shape, and number of objects to assess the risk of perforation. In children, rectal foreign bodies usually present as rectal bleeding.

Figure 9.36

Rectal Foreign Body Top: The metallic outline of two batteries is seen in this x-ray. Bottom: This foreign body (a 7-oz beer bottle) required removal in the operating room. [Courtesy of David W. Munter, MD (top), and Kevin J. Knoop, MD, MS (bottom).]

Differential Diagnosis

Depending on the clinical scenario, the diagnoses of sexual assault or child abuse should be considered.

Emergency Department Treatment and Disposition

Removal can often take place in the ED with sedation of the patient and local anesthesia of the anal sphincter. If the risk of perforation appears high or adequate relaxation and anesthesia cannot be obtained, then the patient is prepared for emergency surgery. After removal, proctoscopic or sigmoidoscopic examination is recommended to rule out perforation or laceration.

Clinical Pearls

1. A Foley catheter or an endotracheal tube may be used to release the vacuum effect of some foreign bodies, and the balloon can be inflated and aid in the removal.

2. A rectal foreign body in a child should raise the suspicion of abuse.

Melena

Associated Clinical Features

Gastrointestinal bleeding commonly presents with the alteration of stool color. By definition, melena is the passage of dark, pitchlike stools stained with blood pigments (Fig. 9.37). Generally, but not always, melena results from bleeding into the upper gastrointestinal tract proximal to the ligament of Treitz. Black stools have been seen with as little as 60 mL of blood in the upper gastrointestinal tract, but melena typically does not develop until 100 to 200 mL is present. Melena can be found in lower bleeds with decreased transit time, as with an obstruction distal to the site of bleeding.

Figure 9.37

Melena The black, tarry appearance of melena in a patient with a duodenal ulcer. (Courtesy of Alan B. Storrow, MD.)

Differential Diagnosis

Melenic stools may occur from swallowed blood, as from epistaxis or other oropharyngeal bleeding. Dark or black stools can also be seen with the ingestion of bismuth salicylate, food coloring, and iron supplements.

Emergency Department Treatment and Disposition

Patients with melenic stools should be evaluated in a monitored setting and undergo assessment for signs and symptoms of hypovolemia and treated accordingly. At least one large-bore intravenous line should be placed and saline infused. Depending on the patient's stability, type-specific packed red blood cells or other blood products may be required. Abdominal radiographs are done to look for free air in the peritoneum, and gastric aspiration should be done to assess for active gastric bleeding. Stable patients who present with melena may be admitted to the ward. Evidence of unstable vital signs, continued bleeding, severe anemia, or comorbid disease warrants admission to the intensive care unit. Consultation with a gastroenterologist should be sought unless patients require more than two units of blood for resuscitation, which would call for surgical intervention.

Clinical Pearls

1. Melena is the most common presenting symptom of bleeding from peptic ulcer disease.

2. Melena represents approximately 200 mL of blood loss in the gastrointestinal tract.