External Hemorrhoid in Young Adult Male

Case at a Glance

A 30-year-old male presented with a 2-day history of mild perianal discomfort and discovered a palpable lump at the anal sphincter.

Patient's Story

The patient reported experiencing mild discomfort around the anal area for approximately 48 hours. He initially self-treated with topical A&D ointment, which provided some symptomatic relief. During self-examination, he discovered a small, palpable mass located at the anal sphincter, which prompted concern and medical consultation. The patient disclosed a history of anal penetrative activities but noted no recent episodes within the past week.

Initial Assessment

Physical examination revealed a small, tender nodule at the anal verge consistent with an external hemorrhoid. The lesion appeared well-circumscribed without signs of thrombosis or significant inflammation.

The Diagnostic Journey

Clinical diagnosis was based on characteristic presentation and physical findings. Differential diagnosis included external hemorrhoid, perianal hematoma, or anal skin tag. Given the acute onset and associated discomfort, external hemorrhoid was the most likely diagnosis.

Final Diagnosis

External hemorrhoid (non-thrombosed)

Treatment Plan

Conservative management with topical anti-inflammatory ointment, warm sitz baths, increased fiber intake, and adequate hydration. Patient counseled on proper anal hygiene and advised to avoid straining during bowel movements.

Outcome and Follow-up

Patient advised to follow up if symptoms worsen or fail to improve within one week. Counseling provided regarding risk factors and prevention strategies for future episodes.