MEDizzy - You are evaluating a 30-year-old male patient in the office

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Acute Complaints

You are evaluating a 30-year-old male patient in the office with hematochezia. He has had chronic constipation, and reports bright red blood from his rectum associated with extremely painful bowel movements. After defecation, he complains of a dull ache and a feeling of “spasm” in the anal canal. The pain resolves within a few hours. On external examination, no abnormalities are noted. Which of the following is his most likely diagnosis?

ExplanationAn anal fissure is a split in the anoderm of the anal canal. It generally occurs after the passage of a hard bowel movement. Patients present with excruciating pain on defecation with blood found on the toilet paper. After the bowel movement, the patient may complain of an ache or spasm that resolves after a couple of hours. Thrombosed external hemorrhoids would generally be visible on examination. Internal hemorrhoids are generally not painful, unless they are thrombosed because of an unreducible prolapse. If that were the case, the pain would not resolve. A perianal abscess may not present with bleeding, but would likely be associated with systemic signs of infection.