There is a tender, fluctuant mass in the right perirectal area with overlying erythema. As well, the mother states the child has had serious problems with constipation over the last three weeks and cries loudly during each bowel movement. Examination reveals a 1 cm tear in the perianal skin in the posterior midline. The itching is noted to be worse at night, often awaking her from sleep. She describes her personal hygiene as scrupulous.
Examination reveals marked erythema and excoriation of the perianal area.
Work-up including barium enema and sigmoidoscopy fails to reveal any other colorectal pathology. Initially, the protrusion spontaneously reduced, but on several occasions recently, manual reduction has been required. Also, she has noted some recent episodes of anal incontinence. Examination is unremarkable except for a somewhat lax internal sphincter.