Perianal and Buttock Swelling

Karina Irizarry

Michael J. Wilsey Jr.

Approach to the Problem

Pediatricians often encounter concerns about symptoms related to the anorectal region. In children, most of these concerns represent benign entities that seldom require surgical intervention. Symptoms may include perianal masses, rectal pain, bleeding, and pruritus. Careful review of the history, with particular attention to bowel movement patterns and associated symptoms, will help guide the physical examination and facilitate identification of the problem.

Key Points in the History

Perirectal abscesses are more common in infants and children who are less than 1 year of age.
Inflammatory bowel disease (IBD), human immunodeficiency virus (HIV) infection, diabetes mellitus, and neutrophil dysfunction may predispose children to develop perirectal abscesses.
Perirectal abscesses present with perianal pruritus, redness, swelling, or a lump near the anus. They are very painful, and the pain worsens with movement, sitting, and defecation (and diaper changing in infants).
Multiple draining midline sinus tracts that often soil underclothes with cloudy or bloodstained discharge may accompany pilonidal abscesses.
Skin tags, rectal prolapse, and hemorrhoids in children usually result from functional constipation. A history of large, hard, and painful bowel movements and/or encopresis should be considered.
A history of bright red, blood-streaked stools, blood dripping into the toilet, or blood seen on the toilet paper after wiping is suggestive of a perianal fissure.
A fibrotic “sentinel” skin tag may be present over a chronic fissure.
Large, edematous, shiny perianal skin tags should raise concern about the presence of Crohn disease.
External hemorrhoids are varicose veins involving the skin surrounding the anus. They rarely cause symptoms.

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Acutely thrombosed external hemorrhoids present as a sudden onset of throbbing, burning pain at the end of defecation associated with a new bulge in the anal region.
Internal hemorrhoids, which arise from the rectal submucosa, are uncommon in children and should raise concern for portal hypertension.
Anogenital warts are often asymptomatic and found incidentally by parents or physicians.
Anogenital warts in children may be acquire vertically during birth or by autoinoculation from common hand warts.

Key Points in the Physical Examination

A localized tender, well-defined, fluctuant mass may be palpated on the anal verge or on digital examination whenever there is a perirectal abscess.
Ischiorectal abscesses are often large and visible on the surface of the buttock.
Pilonidal abscess occur at the site of an ingrown hair follicle and present as a midline sacral boil approximately 1 to 2 cm above the anus. If the boil spontaneously drains, it may be associated with a fistulous tract.
A hard, painful bluish lump may be seen in the anal opening whenever there is a thrombosed, external hemorrhoid.
Ninety percent of anal fissures are located at the six o’clock position (midposterior region), with the 12 o’clock position (midanterior region) being the next most common. Anal fissures in unusual locations should raise concern about inflammatory bowel disease (IBD), occult abscesses, and infections such as herpes or syphilis.
Anogenital warts will turn white when soaked in 3% to 5% acetic acid (vinegar).
Rectal prolapse may involve only the mucosa or all layers of the rectum (most commonly). In complete prolapse, concentric rings of rectal mucosal are seen herniating through the anus on examination.
After reduction of rectal prolapse, the anal tone may be absent or decreased during rectal examination. The normal tone will return after several hours.

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Figure 56-1 Perianal skin tag. A “sentinel” perianal skin tag seen in a female infant. (Courtesy of Mary L. Brandt, MD.)

Figure 56-2 Perirectal abscess. A 12-month-old male presenting with a perirectal mass. (Courtesy of Mark A. Ward, MD.)

Figure 56-3 Perianal Crohn disease in a child with multiple large, edematous skin tags and a perianal fissure at the 7-o’clock position. (Courtesy of Martin Fried, MD.)

Figure 56-4 External hemorrhoid in a 2-year-old male with recurrent straining because of chronic constipation. (Courtesy of Michael J. Wilsey, Jr., MD.)

Figure 56-5 Rectal prolapse seen in a male infant. (Courtesy of Mary L. Brandt, MD.)

Figure 56-6 Rectal prolapse. Concentric rings of rectal mucosa (all the layers of the rectum) are seen herniating through the anus, indicating a complete prolapse. (Courtesy of Fernando L. Heinen, MD.)

Figure 56-7 Perianal condylomata seen following sexual abuse. (Courtesy of Fernando L. Heinen, MD.)

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DIAGNOSIS	ICD-9	DISTINGUISHING CHARACTERISTICS	DISTRIBUTION	DURATION/CHRONICITY	ASSOCIATED FINDINGS	COMPLICATIONS	PREDISPOSING FACTORS
Perirectal Skin Tag	455.9	Painless, shapeless lumps or flaps of skin or flesh Painful defecation when associated with anal fissure	Anal verge Sentinel tags from above chronic anal fissures	Chronic	Anal pruritus Rectal bleeding	Hygiene-related problems (may impair cleaning of perineum when wiping)	Constipation Fissures Fistulas Injury from rectal surgery Hemorrhoids
Perirectal Abscess	566	Tender, fluctuant mass near anus or upon digital exam Pilonidal abscess—midline boil +/- fistula	Perianal (60%) Intersphincteric Ischiorectal Supralevator	Present until it drains spontaneously or surgically	Fever Perianal pruritus Pain worse with defecation	Fistula Recurrence Stricture Incontinence	Infancy More common in immunosuppressed patients and patients with diabetes mellitus
Hemorrhoids	455.6	Firm bulge at anal verge, may have bluish discoloration Usually asymptomatic Can be acutely painful when thrombosed (external)	External (below dentate line)—most common Internal (above dentate line)—rare in pediatrics	Acute pain lasts hours to 1–2 weeks (until spontaneously or surgically corrected)	Painless rectal bleeding Occasional discomfort with defecation Anal pruritus	Thrombosis Prolapse Strangulation	Constipation often precedes external hemorrhoids Portal hypertension may precede internal hemorrhoids
Rectal Prolapse	569.1	Painless, bright-red tissue protruding from anus In mucosal prolapse, radial folds seen at junction with anal skin In complete rectal prolapse, circular folds seen at junction with anal skin Highest incidence in the first year of life	Anal herniation of rectal mucosa	May become chronic, occurring with most bowel movements (weeks to months)	Pruritus Bleeding Urgency	Edema and necrosis of prolapsed tissue Fecal incontinence	Constipation Acute or chronic diarrhea Chronic lung disease Cystic fibrosis Pelvic floor weakness because of myelomeningocele, postanal surgery, or Ehlers Danlos syndrome Parasitic infestations, especially with Trichuriasis (whipworm) Hirschsprung disease Malnutrition Congenital hypothyroidism
Anogenital Warts	078.19	Four types: Condyloma acuminatum-cauliflower-like lesions Flat-macular Papular Keratotic-thick, crusty Usually multiple	May be found as discrete lesions or may coalesce to form plaques	N/A	Can be friable, pruritic, and painful	Cancer (very rarely)	Human papillomavirus (HPV) infection (low risk types: 6,11) Sexual abuse Autoinoculation from hand wart

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Other Diagnoses to Consider

Protruding colonic polyp
Protruding ileocecal intussusception
Chronic solitary ulcer

	Visual Diagnosis in Pediatrics 1st Edition
	© 2006 Lippincott Williams & Wilkins

Visual Diagnosis in Pediatrics1st Edition

Visual Diagnosis in Pediatrics
1st Edition