Ano-rectal Region and Perineum
1. A 42 year old male presents with concerns of finding “bright red blood in the toilet.” He denies any pain, burning, itching or trauma to his rectum. Although this is the first time he has noted blood that reddened the water he has seen blood on his toilet paper before. He has never noted blood mixed with his stool. He denies any diarrhea but has been more constipated recently.
What is your differential diagnosis for this man’s symptoms?
If you were to perform an anoscopy on this patient, what landmark would help you differentiate the most likely causes of rectal bleeding?
2. A 62 year old female comes to your office with complaints of having “accidents.” She initially had episodes of urinary incontinence just when she would cough or sneeze but now is having episodes with daily activities. She denies any dysuria, urgency or frequency. She reports no abdominal or pelvic pain. She has full sensation in her perineum and has had no episodes of fecal incontinence. Her past medical history is only significant for early osteoarthritis. Her gynecological history is remarkable for two normal spontaneous vaginal deliveries and menopause at age 52 years.
What are some of the possible anatomic mechanisms that would be responsible for this patient’s symptoms?
What treatment might you initially prescribe to help with this condition?
3. A 58 year old homeless man is brought into the emergency department obtunded and febrile. The EMT’s accompanying him stated that he was complaining of groin pain prior to becoming unresponsive. On physical exam, the man appears ashen and does not respond to verbal stimuli. He is febrile at 40.1 C, tachycardic with a pulse of 122 and weak, blood pressure was 70 over palp, and respirations were 32 per minute. His perineum is erythematous, edematous and has areas of necrosis that extends on to his scrotum, which is massively enlarged.
What general process is occurring in this gentleman and what do you believe the appropriate treatment might be?
What might be the potential complications of this process given the anatomic location?
A 28 year old female presents to your office with complaints of abdominal pain and bloating. It began approximately three days prior and has been worsening in intensity. The pain is generalized, colicky in nature, non-radiating, without associated vomiting. She has been nauseated the last 24 hours. She reports no bowel movement for 6 days. She denies weight loss. She denies pregnancy but states that she hasn’t had her menses for the last 6 months. On physical exam, the patient is a frail appearing young female with mild abdominal distention who was in mild distress, assuming the fetal position. The abdomen was tympanitic with scant bowel sounds that were occasionally high pitched. There were no peritoneal signs present.
What is your differential diagnosis for this patient’s symptoms? What part of the physical exam do you want to perform at this point?
What are some of the potential anatomic mechanisms for constipation/obstipation?
A 32 year old very distraught female comes to your office with complaints of fecal incontinence. Every since the delivery of her second child she has noted that her ability to control her bowel movements has been compromised. On pelvic exam, she has normal sensation to the perineum and associated structures. No rectocele is present. However, her rectal exam displays poor anal sphincter tone.
What may have been the etiology of this patient’s stool incontinence? What anatomic structures were likely damaged in this process?
What might be the potential treatment(s) for this patient’s condition and potential complications?