Rosh Emergency Medicine Practice Test

In a patient with acute perianal pain, what is the recommended treatment for a tense, tender, purplish mass in the perianal area?

1. Consult surgery for incision and drainage in the operating room

2. Discharge with stool softener and topical analgesics

3. Perform excision with clot evacuation in the emergency department

4. Perform rubber band ligation of the hemorrhoid

The correct answer is: Perform excision with clot evacuation in the emergency department

In the case of a tense, tender, purplish mass in the perianal area, the clinical presentation is suggestive of a thrombosed external hemorrhoid or possibly a perianal abscess. The recommended treatment involves excision with clot evacuation in the emergency department, particularly when the mass is acute and painful. This approach is appropriate because it addresses both the pressure and pain associated with the thrombosis or abscess. By excising the thrombosed tissue or draining an abscess, the pressure is relieved, which significantly alleviates pain and prevents further complications such as infection or necrosis. Management that involves other modalities, such as consulting surgery for incision and drainage in the operating room, may not be immediately necessary and can delay treatment when the procedure can safely be performed in the emergency setting. Discharging the patient with stool softeners and topical analgesics does not address the acute issue and may leave the patient in significant discomfort, while rubber band ligation is primarily indicated for chronic hemorrhoids and not for the acute presentation indicated by the question. Thus, excision with clot evacuation directly addresses the urgent needs of the patient.