What is the diagnosis for a 39-year-old male with rectal and perineal pain, improved with hydrocortisone suppositories, and normal laboratory results?

From the Guidelines

I strongly recommend switching the patient from hydrocortisone suppositories to mesalamine suppositories, as the latest evidence suggests that mesalamine suppositories are more effective for inducing remission in patients with mild-moderate ulcerative proctitis 1. The patient's symptoms of throbbing pain in the rectum and pain between the rectum and scrotum, along with the improvement in condition with hydrocortisone suppositories, suggest a possible diagnosis of ulcerative proctitis. The negative Hemoccult test and normal PSA, CBC, and CMP results are reassuring, indicating no evidence of bleeding, prostate abnormalities, or systemic disease. However, given the potential safety concerns with long-term rectal corticosteroids and the superiority of rectal 5-ASA for inducing remission, topical 5-ASAs, such as mesalamine suppositories, are preferred 1. The patient should be advised to gradually resume physical activity, as this may help improve symptoms through increased blood flow and reduced pelvic floor tension. Additionally, warm sitz baths 2-3 times daily for 10-15 minutes may provide additional relief. If symptoms persist despite these measures, consider adding a muscle relaxant such as cyclobenzaprine 5-10mg at bedtime or diazepam 2-5mg as needed. A referral to a colorectal specialist would be appropriate if symptoms worsen or fail to improve within 4-6 weeks of continued treatment. The patient should be advised to maintain adequate hydration and a high-fiber diet to prevent constipation, which can exacerbate rectal pain. It is essential to monitor the patient's response to the mesalamine suppositories and adjust the treatment plan as needed to ensure the best possible outcome in terms of morbidity, mortality, and quality of life.

From the Research

Patient Symptoms and Treatment

• The patient reports a throbbing pain in his rectum and pain between his rectum and scrotum, with the pain being constant but varying in intensity.
• The patient denies any urinary issues and has seen an improvement in his condition with the use of hydrocortisone suppositories.
• Lab results show Hemoccult NEGATIVE, PSA, CBC, and CMP WNL, indicating no significant abnormalities.

Hydrocortisone Suppositories

• A study published in 2019 2 found that patient self-administration of hydrocortisone can safely achieve superior symptom control for various hydrocortisone-responding disorders.
• Another study from 1998 3 investigated the use of rectal hydrocortisone in patients with adrenal insufficiency and found it to be a safe alternative to parenteral administration.
• A study from 2016 4 found that the dose of hydrocortisone influences pain, depressive symptoms, and perceived health in patients with adrenal insufficiency.

Potential Causes and Treatments

• The patient's symptoms could be related to various conditions, but the use of hydrocortisone suppositories has shown improvement.
• A study from 2023 5 discussed pharmacotherapy for gastric and intestinal cramping pain, but it may not be directly relevant to the patient's symptoms.
• The patient's improvement with hydrocortisone suppositories suggests that the treatment is effective, but further evaluation may be necessary to determine the underlying cause of the symptoms.

Lab Results and Exercise

• The patient's lab results are within normal limits, which suggests that there may not be an underlying infection or other condition that needs to be addressed.
• The patient's decision to stop exercising two weeks ago may be related to his symptoms, but it is unclear if there is a direct connection.