Hemorrhoids are typically diagnosed by physical examination. A visual examination of the anus and surrounding area may diagnose external or prolapsed hemorrhoids. A rectal exam may be performed to detect possible rectal tumors, polyps, an enlarged prostate, or abscesses. This examination may not be possible without appropriate sedation because of pain, although most internal hemorrhoids are not associated with pain. Visual confirmation of internal hemorrhoids may require anoscopy, insertion of a hollow tube device with a light attached at one end. The two types of hemorrhoids are external and internal. These are differentiated by their position with respect to the dentate line. Some persons may concurrently have symptomatic versions of both. If pain is present, the condition is more likely to be an anal fissure or an external hemorrhoid rather than an internal hemorrhoid.

Sinus films are helpful in the diagnosis of sphenoid sinusitis. Opacification, sclerosis, and air-fluid levels are typical findings. Contrast-enhanced CT scan may reveal underlying sinusitis, thickening of the superior ophthalmic vein, and irregular filling defects within the cavernous sinus; however, findings may be normal early in the disease course.

A MRI using flow parameters and an MR venogram are more sensitive than a CT scan, and are the imaging studies of choice to diagnose cavernous sinus thrombosis. Findings may include deformity of the internal carotid artery within the cavernous sinus, and an obvious signal hyperintensity within thrombosed vascular sinuses on all pulse sequences.

Cerebral angiography can be performed, but it is invasive and not very sensitive. Orbital venography is difficult to perform, but it is excellent in diagnosing occlusion of the cavernous sinus.

"Diagnosis" is by examination, either in an outpatient setting or under anaesthesia (referred to as — Examination Under Anaesthesia). The fistula may be explored by using a fistula probe (a narrow instrument). In this way, it may be possible to find both openings. The examination can be an anoscopy. Diagnosis may be aided by performing a fistulogram, proctoscopy and/or sigmoidoscopy.

Possible findings:

- The opening of the fistula onto the skin may be observed

- The area may be painful on examination

- There may be redness

- An area of induration may be felt — thickening due to chronic infection

- A discharge may be seen

CLASSIFICATIONS of ANAL FISTULA

- Park's Classification: This was done in 1976 by Parks et al from UK. This was done in the era when MRI or Endoanal Ultrasound was not there. It classified the fistula in four grades

- St James University Hospital Classification: This was done by Morris et al in the year 2000. This classification was improvement over Parks classification as it was based on MRI studies. It classified the fistula in five grades.

- Garg Classification: This was done by Pankaj Garg in 2017. This classification is improvement over both Parks and St James University Hospital Classification. This was based on MRI studies and operative findings in 440 patients. It classified the fistula in five grades. The grades of this classification correlate quite well with the severity of the disease. Grade I & II are simpler fistulas and can be managed by Fistulotomy whereas grade III-V are complex fistulas in which fistulotomy should be not be done. They should be managed by Fistula experts. Unlike Park's and St James University Hospital Classification, this correlation is quite accurate with Garg's classification. Therefore this new classification is useful to both surgeons and radiologists

A number of preventative measures are recommended, including avoiding straining while attempting to defecate, avoiding constipation and diarrhea either by eating a high-fiber diet and drinking plenty of fluid or by taking fiber supplements, and getting sufficient exercise. Spending less time attempting to defecate, avoiding reading while on the toilet, and losing weight for overweight persons and avoiding heavy lifting are also recommended.

CBC, ESR, blood cultures, and sinus cultures help establish and identify an infectious primary source. Lumbar puncture is necessary to rule out meningitis.

Generally gynecologic hemorrhage does not arise out of nowhere. Regular gynecologic examinations, cancer screening, and contraceptive measures go a long way in preventing and forestalling unsuspected acute bleeding events.

Other conditions in which infected perianal "holes" or openings may appear include Pilonidal cysts/sinuses.

Clinical evaluation is the primary diagnostic tool for thrombophlebitis. Patients with thrombophlebitis complain of pain along the affected area. Some report constitutional symptoms such as low grade fever and aches. On physical examination, the skin over the affected vein exhibits erythema, warmth, swelling, and tenderness. Later in the disease, as induration subsides, erythema gives way to a ruddy or bruised color.

Duplex ultrasound identifies the presence, location and extent of venous thrombosis, and can help identify other pathology that may be a source of the patient's complaints. Ultrasound is indicated if superficial phlebitis involves or extends into the proximal one-third of the medial thigh, there is evidence for clinical extension of phlebitis, lower extremity swelling is greater than would be expected from a superficial phlebitis alone or diagnosis of superficial thrombophlebitis in question.

A history will establish if the condition is acute or chronic, and if external circumstances are involved. A gynecologic examination is usually complemented by a gynecologic ultrasonography. A blood count determines the degree of anemia and may point out bleeding problems. The pregnancy test is important, particularly as bleeding in early pregnancy presents as gynecological hemorrhage and ectopic pregnancy can be fatal.

Diagnosis is broadly classified into supportive and definitive investigations:

Several techniques are used to reduce the risk of tearing, but with little evidence for efficacy. Antenatal digital perineal massage is often advocated, and may reduce the risk of trauma only in nulliparous women. ‘Hands on’ techniques employed by midwives, in which the foetal head is guided through the vagina at a controlled rate have been widely advocated, but their efficacy is unclear. Waterbirth and labouring in water are popular for several reasons, and it has been suggested that by softening the perineum they might reduce the rate of tearing. However, this effect has never been clearly demonstrated.

Treatment with compression stockings should be offered to patients with lower extremity superficial phlebitis, if not contraindicated (e.g., peripheral artery disease). Patients may find them helpful for reducing swelling and pain once the acute inflammation subsides.

Nonsteroidal anti-inflammatory drugs (NSAID) are effective in relieving the pain associated with venous inflammation and were found in a randomized trial to significantly decrease extension and/or recurrence of superficial vein thrombosis.

Anticoagulation for patients with lower extremity superficial thrombophlebitis at increased risk for thromboembolism (affected venous segment of ≥5 cm, in proximity to deep venous system, positive medical risk factors).

Treatment with fondaparinux reduces the risk of subsequent venous thromboembolism.

Surgery reserved for extension of the clot to within 1 cm of the saphenofemoral junction in patients deemed unreliable for anticoagulation, failure of anticoagulation and patients with intense pain. Surgical therapy with ligation of saphenofemoral junction or stripping of thrombosed superficial veins appears to be associated higher rates of venous thromboembolism compared with treatment with anitcoagulants.

A varix (pl. varices) is an abnormally dilated vessel with a tortuous course. Varices usually occur in the venous system, but may also occur in arterial or lymphatic vessels.

Examples of varices include:

- Varicose veins, large tortuous veins usually found on legs

- Sublingual varices

- Esophageal varices, commonly stemming from cirrhosis of the liver, also known as oesophageal varicose

- Gastric varices, commonly stemming from cirrhosis of the liver

- Intestinal varices

- Scrotal varices

- Vulvar varices

- Pelvic varices

- Vesical varices, varicose veins associated with the urinary bladder

- Rectal varices, which can be similar to external haemorrhoids

The diagnosis of Ludwig's angina is clinical. History and physical examination are usually enough to establish the diagnosis.

A 2008 study found that over 85% of women having a vaginal birth sustain some form of perineal trauma, and 60-70% receive stitches. A retrospective study of 8,603 vaginal deliveries in 1994 found a third degree tear had been clinically diagnosed in only 50 women (0.6%). However, when the same authors used anal endosonography in a consecutive group of 202 deliveries, there was evidence of third degree tears in 35% of first-time mothers and 44% of mothers with previous children. These numbers are confirmed by other researchers in 1999.

A study by the Agency for Healthcare Research and Quality (AHRQ) found that in 2011, first- and second-degree perineal tear was the most common complicating condition for vaginal deliveries in the U.S. among women covered by either private insurance or Medicaid.

Second-degree perineal laceration rates were higher for women covered by private insurance than for women covered by Medicaid.

Unlike oesophageal varices, rectal varices are less prone to bleeding, are less serious when a bleed does occur, and are easier to treat because of the more accessible location.

Typically, treatment consists of addressing the underlying portal hypertension. Some treatments include portosystemic shunting, ligation, and under-running suturing. Insertion of a transjugular intrahepatic portosystemic shunt (TIPS) has been shown to alleviate varices caused by portal hypertension. Successful treatment of portal hypertension that subsequently reduces anorectal varices provides a confirmation of the initial diagnosis, allowing for a distinction between varices and hemorrhoids, which would not have been alleviated by reduction of portal hypertension.

In many cases, RLP is confused with other conditions that cause abdominal pain. Described below are some problematic diagnoses related to RLP.

- RLP and appendicitis

A 22-year-old pregnant woman presenting abdominal pains was initially diagnosed with RLP and was discharged. Subsequent symptoms and further tests revealed acute non-perforated appendicitis that required surgery. Appendectomy was successful but premature labor occurred 7 days after discharge, leading to spontaneous abortion.

- RLP and inguinal hernia

Several cases of varicosity, of the round ligament during pregnancy leading to RLP have been reported although they were frequently misdiagnosed as inguinal hernia.

In one case, a woman in the 28th week of gestation developed a lump in the left pubic area. The swelling was prominent when standing but not in the supine position and has a cough impulse. Ultrasonography revealed varicosities on the uterine round ligament.

In another case, a woman at 22 weeks gestation was diagnosed with inguinal hernia and underwent surgery. Explorative surgery did not locate a hernia but revealed varicosities of the round ligament. Resection of the uterine ligament was successfully performed and no perinatal and postpartum complications were reported.

- Postpartum RLP

Several cases of postpartum RLP have been reported. In one case, a 27-year-old woman presented with abdominal pain 24 hours after normal vaginal delivery. Another case was that of a 29-year-old woman who presented with RLP 3 days after delivery. In both cases, initial diagnosis was inguinal hernia. In the first case, emergency surgery did not locate any hernia but found the round ligament of the uterus to be edematous and filled with thrombosed varicose veins. The thrombosed part was excised and the patient recovered without sequelae.

Another case report described a 37-year-old woman presenting with inguinal mass 6 days after normal vaginal delivery. CT and MRI revealed thrombosed blood vessels along the inguinal course of the uterine round ligament that extended towards the labia majora.

- RLP and endometriosis

Several cases of inguinal endometriosis, that infiltrates the round ligament of the uterus have been reported in fertile, non-pregnant women. In the majority of these cases, diagnosis was problematic. In some cases, definitive diagnosis of round ligament endometriosis was only possible during exploratory surgery.

- RLP and myoma

Cases of myoma-like growth occurring on the uterine round ligament have been reported.

- RLP and IVF

Gonadotropin stimulation during in vitro fertilization can induce cyst development in certain parts of the female reproductive system. A case report documented the development of a mesothelial cyst on the uterine round ligament of a woman after IVF stimulation.

Abdominal pains during pregnancy may be due to various pathologies. RLP is one of the most common and benign of these pains. However, diagnosis of RLP is problematic. Some of the conditions that may present symptoms similar to those of RLP are appendicitis, ectopic pregnancy, kidney stones, urinary tract infection, uterine contractions, inguinal hernia, ovarian cysts, and endometriosis. If abdominal pain is continuous and accompanied by vaginal bleeding, excessive vaginal discharge, fever, chills, or vomiting, then it is most unlikely to be RLP and immediate consultation with a health care provider is warranted.

Physical examination, ultrasonography, and blood and urine tests may be able to pinpoint the actual cause of abdominal pain. In some cases, however, RLP was only diagnosed during exploratory surgery.

Striae gravidarum (pregnancy-related stretch marks) occur in 50% to 90% of women, and are caused both by the skin stretching and by the effects of hormonal changes on fibers in the skin. They are more common in younger women, women of color, women having larger babies and women who are overweight or obese, and they sometimes run in families. Stretch marks generally begin as red or purple stripes (striae rubra), fading to pale or flesh-color (striae alba) after pregnancy that will generally be permanent. They appear most commonly on the abdomen, breasts, buttocks, thighs, and arms, and may cause itching and discomfort. Although several kinds of multi-component creams are marketed and used, along with vitamin E cream, cocoa butter, almond oil and olive oil, none have been shown to prevent or reduce stretch marks in pregnancy. The safety for use in pregnancy of one herbal ingredient used in some products, Centella asiatica, has been questioned. Some treatments used to reduce scarring, such as topical tretinoin lasers, are sometimes used on stretch marks, but evidence on them is limited. Topical tretinoin has been shown to cause malformations in animals, without adequate human studies on safety in human pregnancies.

Although SRUS is not a medically serious disease, it can be the cause of significantly reduced quality of life for patients. It is difficult to treat, and treatment is aimed at minimizing symptoms.

Stopping straining during bowel movements, by use of correct posture, dietary fiber intake (possibly included bulk forming laxatives such as psyllium), stool softeners (e.g. polyethylene glycol, and biofeedback retraining to coordinate pelvic floor during defecation.

Surgery may be considered, but only if non surgical treatment has failed and the symptoms are severe enough to warrant the intervention. Improvement with surgery is about 55-60%.

Ulceration may persist even when symptoms resolve.

Regurgitation and heartburn in pregnancy are caused by relaxation of the lower esophageal sphincter (LES) and increased transit time in the stomach (normal in pregnancy), as well as by increased intraabdominal pressure, caused by the enlarging uterus.

Regurgitation and heartburn in pregnancy can be at least alleviated by eating multiple small meals a day, avoiding eating within three hours of going to bed, and sitting up straight when eating.

If diet and lifestyle changes are not enough, antacids and alginates may be required to control indigestion, particularly if the symptoms are mild. If these, in turn, are not enough, proton pump inhibitors may be used.

If more severe, it may be diagnosed as gastroesophageal reflux disease (GERD).

These may reveal congestion and edema (swelling) of the distal rectal mucosa, and in 10-15% of cases there may be a solitary rectal ulcer on the anterior rectal wall. Localized inflammation or ulceration can be biopsied, and may lead to a diagnosis of SRUS or colitis cystica profunda. Rarely, a neoplasm (tumour) may form on the leading edge of the intussusceptum. In addition, patients are frequently elderly and therefore have increased incidence of colorectal cancer. Full length colonoscopy is usually carried out in adults prior to any surgical intervention. These investigations may be used with contrast media (barium enema) which may show the associated mucosal abnormalities.

The terms rectal varices and haemorrhoids are often used interchangeably, but this is not correct. Haemorrhoids occur due to prolapse of the rectal venous plexus and are no more common in patients with portal hypertension than those without. Rectal varices, however, are only found in patients with portal hypertension and are common in conditions such as cirrhosis.

Treatment involves appropriate antibiotic medications, monitoring and protection of the airway in severe cases, and, where appropriate, urgent Otolaryngology-Head and Neck Surgery, maxillo-facial surgery and/or dental consultation to incise and drain the collections. The antibiotic of choice is from the penicillin group.

Incision and drainage of the abscess may be either intraoral or external. An intraoral incision and drainage procedure is indicated if the infection is localized to the sublingual space. External incision and drainage is performed if infection involves the perimandibular spaces.

A nasotracheal tube is sometimes warranted for ventilation if the tissues of the mouth make insertion of an oral airway difficult or impossible.

In cases where the patency of the airway is compromised, skilled airway management is mandatory. Fiberoptic intubation is common.

Ludwig's angina is a life-threatening condition, and carries a fatality rate of about 5%.

Umbilical cord compression may be relieved by the mother switching to another position. In persistent severe signs of fetal distress, Cesarean section may be needed.

Physical examination can rule out anismus (by identifying another cause) but is not sufficient to diagnose anismus.