OSCE: Rectal pain x 1 day

RJ is a 56 year old male with PMHx of hypertension and hypercholesterolemia who presents to the ED complaining of sharp intense rectal pain that started yesterday and has progressively worsened.

History Elements:

  • Onset: Yesterday night 
  • Location: patient states “inside his rectum”
  • Symptoms:
    • Pertinent Positives: rectum pain, swelling of the rectum, history of hemorrhoids, abdominal tenderness, pain with defecation 
    • Pertinent Negatives: fever, trauma, constipation, urinary urgency, frequency, or burning, blood in stool, rectal bleeding, back pain and insertion of foreign body
    • Aggravating Factors: sitting, applying pressure against buttock 
    • Alleviating Factors: laying down on his side
  • No previous history of experiencing this sensation before 
  • Drug Allergies: No known drug, seasonal or food  allergies 
  • Medications: Atorvastatin 40 mg QD, Amlodipine 10 mg QD 
  • Past Medical History: Hypertension and hypercholesterolemia
    • Immunizations up to date including COVID and Flu 
  • Past Surgical History: Patient denies any  surgery including eye, hernia, appendix or gallbladder surgery 
  • Past Family History: Patient is unsure of parents and grandparents history. 
  • Social History: 
    • Entered into the USA in January and is residing with his cousin 
    • Alcohol use: Occasional, a beer once or twice a month 
    • Tobacco and illicit drug use: Denies any 
    • Diet consist of traditional Haitian food
    • Exercise consist of patient walking and trying to remain active 
    • Patient is heterosexual and sexually inactive with the last sexual encounter being 3 years ago. No prior history of STIs

Physical Exam:

  • Vitals: BP- 138/88 mmHg, RR – 17/min, unlabored, HR- 98 bpm, regular, T – 37.6 degrees celsius,  O2 sat – 94%, Ht- 5ft 6in, Wt- 178 lbs, BMI- 28.7
  • General: Anxious appear male who appears younger than stated age of 56. Patient is pacing the ED and cannot keep still while clenching his buttocks with his left hand. 
  • Skin: warm and moist with good turgor, non icteric, no lesions, no scars and no tattoos. 
  • Cardiac: PMI in 5th ICS in mid clavicular line, Regular rate and rhythm, S1 and S2 are distinct with no murmurs, no gallops, S3 or S4
  • Abdomen: Soft symmetric with no striae, no scars, lesions, masses, hernia or pulsations. Negative rebound and guarding. Bowel sounds normoactive in all 4 quadrants with no bruits. 
  • Male Genitalia/Rectal: uncircumcised male with no swelling or tenderness Skin is warm, moist and smooth with no excoriations, scars, masses or lesions. No visible hemorrhoids seen and none palpated. Prostate not appreciated
  • Neurologic: No obvious focal deficits, clear fluent speech with sensation intact

Differentials:

  • Anal Fissure: Presents as deep burning pain within the rectum that worsens with bowel movements. Patients can present with complaints of anal itching and/or dryness, and a small amount of bright red blood when wiping. Unlikely as the patient denies any blood in rectum and no fissure felt during the rectal exam. Will order a CT Abdomen and Pelvis (CTAP) to rule out
  • Prostatitis: Presents with pain in the groin, pelvic area and sometimes referred pain to the rectum, fever, chills , urinary symptoms (frequency, urgency, nocturia), In history patients may have previous STI, UTI, or history of catheter placement. On exam, the prostate will appear tender and boggy. Unlikely due to being unable to appreciate the prostate. Prostate most likely not inflamed. Will rule out possibility with UA, STI test and CTAP 
  • Foreign body in Rectum: Patient usually presents with history of placing an object there, intense rectum pain, difficulty walking or with micturition, abdominal pain, fever and constipation. Unlikely due to denial of placing objects in rectum. Will rule out with CT abdomen and Pelvis 
  • IBD- Crohns: Presents with fever, fatigue, diarrhea, blood in stool, intense pain in rectum, drainage in rectum due to inflammation and abdominal pain. Unlikely due to no blood in stool and no fever. Will rule out with CT abdomen and pelvis (CTAP). CTAP can show inflammation, tears, bleeding and/or obstruction of the intestinal lining. 

Test:

  • CBC – Unremarkable 
  • CMP – Unremarkable 
  • UA – Unremarkable, clear yellow urine with no signs of leukocytes or nitrites 
  • STD panel – Unremarkable:  Chlamydia, Gonorrhea, Rapid HIV and Syphilis all negative
  • CT Abdomen and Pelvis with and without contrast: Depicts a radiopaque foreign body deep within the rectum lying diagonally from one end to another of the rectum.Normal sized prostate with no inflammation, no tears or inflammation noted in the intestinal lining, no fissures noted in the rectum. 

Assessment:

RJ is a 56 year old male with PMHx of hypertension and hypercholesterolemia who presents to the ED complaining of sharp intense rectal pain that started yesterday and has progressively worsened. CTAP shows a radiopaque foreign body lodged deep within the rectum. 

Treatment:

  • Toradol for pain 
  • Surgery and GI consults:
    •  Surgery has to clear the patient to have surgery 
    • GI to perform therapeutic colonoscopy to remove foreign body
      • Colonoscopy reveals undigested food stuck within rectum , most likely a fish bone. 

Patient counseling:

  • Explain that although rare , it is possible for food to get stuck within the rectum and cause the intense pain that he was feeling. 
  • Advise him to properly chew his food and to be careful with bones
  • Advise him to follow up with his PCP in regards to his PMHx

References:

Davis NG, Silberman M. Bacterial Acute Prostatitis. [Updated 2023 May 22]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK459257/

Ranasinghe IR, Hsu R. Crohn Disease. [Updated 2023 Feb 20]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK436021/

Jahnny B, Ashurst JV. Anal Fissures. [Updated 2022 Nov 14]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK526063/

Sajjad H, Paish LM. Rectum Foreign Body Removal. [Updated 2023 Mar 11]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK557557/