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Paraproctitis - Diagnosis
Medical expert of the article
Last reviewed: 06.07.2025
Diagnosis of acute paraproctitis
The most important examination of the anal area and digital examination of the rectum are of the greatest importance in recognizing acute paraproctitis.
On examination, attention is drawn to hyperemia of the skin in the perineum on the affected side. When the abscess is located in close proximity to the anus, the anus is deformed. Palpation of the perineum is painful. Fluctuation may be determined. Digital examination of the rectum is also painful in many cases and should be carried out with caution. This technique cannot be neglected, since the information obtained with its help can be very valuable for recognizing almost all forms of acute paraproctitis. In subcutaneous paraproctitis, which accounts for approximately 50% of all cases of acute paraproctitis, digital examination makes it possible to determine the infiltrate, including its upper border. In submucous paraproctitis, which occurs in 1.9-6.3% of patients with acute paraproctitis and is related to mild forms of the disease, digital examination can detect a round, stiff submucosal formation protruding into the lumen of the rectum above the pectineal line. Ischiorectal paraproctitis is much more common (35-40% of the total number of patients with acute paraproctitis). Paraproctitis of this localization is also characterized by infiltration of the wall of the lower ampullar part of the rectum and the anal canal above the pectineal line. The infiltrate may not be detected only in cases where pus quickly spreads to the subcutaneous tissue and breaks through to the skin of the perineum. In a rare severe form of acute paraproctitis - pelvic rectal (pelviorectal) - a digital examination allows us to identify the initial signs of this lesion: pain on palpation of one of the walls of the middle or upper ampullar part of the rectum, its doughy consistency or dense infiltrate. The upper pole of the pelviorectal infiltrate usually cannot be determined with a finger. Rectosigmoidoscopy reveals hyperemia and velvetiness of the mucous membrane in the area adjacent to the infiltrate. When the infiltrate bulges into the intestinal lumen, the mucous membrane above it loses its folds, and at the time of the rectoscopy, it bleeds diffusely (contact bleeding).
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Diagnosis of chronic paraproctitis
When interviewing a patient, the duration of the disease, frequency of exacerbations, and treatment methods used are clarified.
During the examination, attention is paid to the condition of the skin of the perineum. Palpation of the perianal area and perineum allows one to determine the presence of a cicatricial process and the degree of its development.
Digital examination of the rectum makes it possible to judge the tone of the sphincter and, in some cases, to detect the internal opening of the fistula.
Probing with a metal button probe is mandatory, which is inserted into the fistula through its external opening. The probe is used to determine the direction of the fistula and its relation to the sphincter muscle.
The test with a dye is used to determine the patency of the fistula tract, the location of the internal opening and purulent cavities in the tissue.
Fistulography is a mandatory X-ray examination of rectal fistulas, especially important for identifying trans- and extrasphincteric fistulas.
Rectosigmoidoscopy is performed to detect concomitant inflammatory diseases, tumors and high-lying internal fistula openings.