Which of the following is the most appropriate next step? A 23-year-old woman seeks help for exquisite pain with defecation and blood streaks on the outside of her stools, which she has been having for several weeks. Because of the pain, she has avoided having bowel movements, and when she finally did the stools were hard and even more painful. When seen, she has no fever or leukocytosis. Physical examination has to be done under spinal anesthesia because the patient was so afraid of the pain that she initially refused even inspection of the area. The examination confirms the suspected diagnosis, and she is placed on stool softeners and appropriate topical agents but without success. She is willing to undergo more aggressive treatment.
A. Excision of the lesion B. Fistulotomy C. Incision and drainage D. Lateral internal sphincterotomy E. Rubber band ligation
If a young woman is experiencing pain when she uses the bathroom, she may hold her bowel movements for a longer period of time. This would not help because it would just make the bowel movements even more painful. Stool softeners may be prescribed for the patient so that it makes going to the bathroom much easier.
However, this just helps with one symptom and it does not actually stop the problem. The woman will have to go to the doctor’s and get a prescription or a procedure to stop her problem. The next step besides going to the doctor’s office would be to perform a lateral internal sphincterotomy. The lateral internal sphincterotomy is a procedure that causes the pressure to lessen.
Lateral internal sphincterotomy -the clinical picture is classic for anal fissure, which is perpetuated by the fact that the anal sphincter is too tight. forceful dilatation under anesthesia, lateral sphincterotomy, or botulinum toxin injections are acceptable options to break the cycle. the only one of those choices given is the sphincterotomy. excision (choice a) used to be done for this condition, before the role of the too tight sphincter was elucidated. fistulotomy (choice b) is not the answer. she has a fissure, not a fistula. incision and drainage (choice c) is another option that addresses a wrong diagnosis. we do that for perirectal abscess, which produces severe pain with fever and leukocytosis, but without blood streaks, and drains spontaneously after several days if not diagnosed and treated. rubber band ligation (choice e) is the answer for internal hemorrhoids. internal hemorrhoids can bleed, but typically do not hurt. thrombosed external hemorrhoids can hurt tremendously, but those are not amenable to rubber band ligation.