Diagnosis: Hemorrhoids
Based on the clinical presentation of 10 days of rectal bleeding during and after defecation combined with perianal itching and discomfort, the diagnosis is hemorrhoids (B), not anal fissure. 1
Key Distinguishing Clinical Features
Why Hemorrhoids is the Correct Diagnosis
Bleeding pattern: Bright red blood during and after defecation for 10 days is the hallmark presenting symptom of internal hemorrhoids, occurring when prolapsed hemorrhoidal tissue is traumatized during bowel movements 1
Perianal itching and discomfort: These symptoms arise from prolapse of internal hemorrhoidal tissue through the anal canal, which deposits mucus onto the perianal skin, causing chemical irritation, itching, and visible inflammation 1, 2
Absence of severe pain: The patient reports "discomfort" rather than severe pain, which is critical—uncomplicated internal hemorrhoids typically do not cause significant pain 1, 3
Why Anal Fissure is Unlikely
Pain characteristics are wrong: Anal fissure presents with severe, sharp postdefecatory pain that patients describe as "passing glass" or "tearing," often lasting 30 minutes to several hours after bowel movements 1, 2
The cardinal symptom of anal fissure is pain, not itching: While fissures can bleed, the defining feature is excruciating pain during and especially after defecation, which this patient does not report 1
Fissures rarely cause perianal itching: The itching described here is pathognomonic for mucus deposition from prolapsed hemorrhoidal tissue, not fissure pathology 1, 2
Critical Diagnostic Pitfall to Avoid
Never assume all anorectal symptoms are simply hemorrhoids without proper examination—physicians should not make the same assumption patients make 1, 2. However, in this specific case, the symptom constellation (bleeding + itching + discomfort without severe pain) strongly points to hemorrhoids rather than fissure 1, 3.
Essential Next Steps
Perform anoscopy with adequate lighting to visualize internal hemorrhoids, identify the source of mucus production, and definitively exclude anal fissure 1, 2
Digital rectal examination is mandatory to assess for masses, induration, and sphincter tone, though internal hemorrhoids themselves are typically not palpable because they are soft, compressible vascular cushions 2
Consider flexible sigmoidoscopy or colonoscopy if bleeding is atypical, no source is evident on anorectal examination, or the patient has risk factors for colonic neoplasia, as hemorrhoids alone do not cause positive stool guaiac tests 1, 3
Coexistence Caveat
Up to 20% of patients with hemorrhoids have concomitant anal fissures 2, 3. If examination reveals both pathologies, the hemorrhoids are still the primary cause of the itching and prolonged bleeding pattern described, while any fissure would explain severe pain if present 1, 2.