This 40-year-old man presented with a very painful infection. There was a large abscess which was easily palpable with surrounding cellulitis. It clearly needed incision so he was admitted for this to be done under general anaesthetic. There was no obvious underlying cause, such as inflammatory bowel disease or diabetes. Following drainage, the abscess cavity required regular dressing but healed well.
This man rather sheepishly requested help with the removal of this perianal lesion. It had been present for some years, but his new partner did not like it, making him seek help. He was referred and it was removed easily. Histology confirmed the benign nature of the lesion. The cause is unknown, but patients often have more than one lesion, and as in this case, they can become quite large. They are always benign.
This is a painful tear in the perianal skin. It usually results from overstretching of the anus, and presents with pain on defecation often associated with a small amount of fresh red bleeding, usually noted on the paper. Advice about straining and diet, along with use of topical agents such as nitrates and stool softeners, usually results in healing. Occasionally, fissures may be associated with an underlying problem such as inflammatory bowel disease.
Psoriasis can be a very difficult condition to diagnose. This 40-year-old diabetic man had no obvious history of psoriasis anywhere else on his body. He complained of longstanding irritation. To make the diagnosis even more difficult, he had spent some time applying a wide range of OTC creams to the area. The advice given was to avoid any possible irritants and use a combination cream with a topical steroid and antifungal. His symptoms significantly improved.
Piles are probably the most common perianal problem that we see in general practice. This elderly man was worried as he had a history of occasional bright red rectal bleeding which he had managed with OTC topical agents. He had recently become aware of a new swelling. He was referred and sigmoidoscopy confirmed the presence of internal and external haemorrhoids. He was treated with injection sclerotherapy but had further problems in the following months. He eventually had a formal haemorrhoidectomy.
Thrombosed external pile
In this case, the classical presentation was of a new and acutely painful swelling. Examination revealed this thrombosed external pile. It had already leaked a little blood, reducing the level of acute pain. In the past, these were incised in the surgery and immediate relief was provided. This was not an option that the patient wanted and as the pain was manageable, he decided to wait and see.
This condition usually presents with the complaint of irritation. It has usually been there for some time as patients are reluctant to present. The patient may have a history of eczema elsewhere, but this is often not the case. The skin is damaged and often inflamed. There may be pigmentation in the area. It can be a very difficult condition to control. The patient should avoid using products containing perfumes and, ideally, wear loose-fitting cotton underwear. A steroid cream of moderate potency is often required to control the condition initially, along with a soap substitute. There may be fungal superinfection. It is worth taking a swab to ensure there is no streptococcal infection.
An 80-year-old man was very distressed by the problem of persistent faecal leakage. Causes such as diet and medication were excluded. He was referred for investigation but no obvious cause was found. The only treatment that seemed to help was the use of an anal plug. He was not keen on the idea, and insisted on a second opinion, which came to the same conclusion. When he finally started using them, he found that it did give him a little extra security, allowing him to enjoy his social life again.
Dr Marazzi is a GP in East Horsley, Surrey