What is the differential diagnosis for a 64-year-old male with a history of laparoscopic extralevator abdominoperineal resection (APR) in 2015 and perianal sinus excision in 2019, now presenting with six weeks of hemopurulent exudate from the anal cleft?

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Last updated: April 30, 2025 • View editorial policy

Differential Diagnosis for 64M with Hemopurulent Exudate from Anal Cleft

Single Most Likely Diagnosis

  • Chronic Presacral Sinus or Fistula: Given the patient's history of laparoscopic extralevator abdominoperineal resection (APR) in 2015 and perianal sinus excision in 2019, the most likely diagnosis is a chronic presacral sinus or fistula. The presence of hemopurulent exudate from the anal cleft suggests an ongoing infectious process, which is consistent with a complication from previous surgeries.

Other Likely Diagnoses

  • Anal Fistula: An anal fistula could be a cause of the hemopurulent exudate, especially given the patient's surgical history. Fistulas can be a complication of both APR and perianal sinus excision.
  • Perianal Abscess: Although the patient has had perianal sinus excision, a new perianal abscess could form, leading to hemopurulent discharge.
  • Rectal Prolapse or Mucosal Protrusion: Post-surgical changes could lead to rectal mucosal prolapse or protrusion, causing irritation and potentially leading to discharge.

Do Not Miss Diagnoses

  • Malignancy (e.g., Recurrence of Rectal Cancer): Given the patient's history of APR, which is often performed for rectal cancer, it is crucial not to miss a potential recurrence. Malignancies can cause fistulas, abscesses, or sinus tracts, presenting with similar symptoms.
  • Necrotizing Soft Tissue Infection: Although less common, necrotizing soft tissue infections are life-threatening and can present with signs of infection such as purulent discharge. Early recognition is critical.

Rare Diagnoses

  • Actinomycosis: A rare bacterial infection that can cause chronic abscesses, fistulas, and sinus tracts, especially in the pelvic region. It's more common in patients with a history of abdominal surgery or instrumentation.
  • Tuberculous Fistula: Although rare in many parts of the world, tuberculosis can cause fistulas and sinus tracts, particularly in immunocompromised patients or those from endemic areas.
  • Crohn's Disease: If not previously diagnosed, Crohn's disease could present with perianal disease, including fistulas and abscesses, leading to hemopurulent discharge. However, the patient's age and surgical history make this less likely as a new diagnosis.

Professional Medical Disclaimer

This information is intended for healthcare professionals. Any medical decision-making should rely on clinical judgment and independently verified information. The content provided herein does not replace professional discretion and should be considered supplementary to established clinical guidelines. Healthcare providers should verify all information against primary literature and current practice standards before application in patient care. Dr.Oracle assumes no liability for clinical decisions based on this content.