Chapter 14 — Paediatric and Adolescent Anorectal Conditions

Purpose: children are not small adults — most anorectal problems in childhood are functional or self-limiting, but intussusception, streptococcal dermatitis, cystic fibrosis, Hirschsprung disease, and abuse must never be missed.

🎨 INFOGRAPHIC / VISUAL BLUEPRINT — CHAPTER 14

• Chapter colour palette: Sunrise Orange (#C2410C) header bar, Warm Cream (#FFF7ED) panels, Dark Umber (#431407) text.
• Hero graphic: A child-friendly examination scene (child on a parent’s lap, nurse chaperone, clinician at eye level) above an age ladder — infant, toddler, school-age, adolescent — showing the common condition and the must-not-miss diagnosis at each age, with a safeguarding shield in the corner.
• Icon set: Teddy bear, child Bristol chart, adhesive tape (threadworm test), streptococcus chain, polyp, sweat drop (cystic fibrosis), safeguarding shield.
• Bedside aphorism banner: “Treat the constipation, look before you touch, and listen when a child’s story does not fit the findings.”

1. Examining a Child

• Explain to the child and the parent; a parent or guardian and a chaperone should be present.

• Inspection is usually enough. A DRE is not needed to diagnose functional constipation and should be reserved for diagnostic uncertainty or red flags, performed by an experienced clinician (ESPGHAN/NASPGHAN 2014; NICE CG99) [S].

• Never force an examination; consider examination under anaesthesia when it is essential.

• Adolescents: offer part of the consultation alone; explain confidentiality and its limits; consent rules vary by country [L].

2. Common and Must-Not-Miss Conditions

Table 14.1 — Paediatric anorectal conditions

3. Sexual Abuse Red Flags and Safeguarding

Every clinician has a duty to act on safeguarding concerns according to national law [L]. Recognise; do not investigate.

Table 14.2 — Safeguarding indicators and actions

Reference: RCPCH, The Physical Signs of Child Sexual Abuse (2015) [C].

Algorithm 14.1 — Child with an anorectal symptom

[CHILD WITH PAIN, BLEEDING, ITCH, OR A LUMP]
|
+-- EMERGENCY? bilious vomiting, colicky pain, lethargy,
|   "redcurrant jelly" stool, distension, shock, bloody
|   diarrhoea with pallor or low urine output
|     -> RED: paediatric emergency team (intussusception,
|        volvulus, HUS, Hirschsprung enterocolitis)
|
+-- SAFEGUARDING CONCERN? disclosure, STI, unexplained
|   anogenital injury, inconsistent story
|     -> child-protection procedure NOW; ensure safety;
|        record the child's words; specialist forensic
|        examination - do NOT examine in detail yourself
|
+-- Hard stools, withholding, painful defecation
|     -> functional constipation (+/- fissure): macrogol
|        disimpaction then maintenance; toilet routine
|        red flags (late meconium, poor growth, neuro
|        signs) -> paediatric referral
|
+-- Night itch -> threadworm: treat the household
+-- Bright-red demarcated rash -> strep swab; penicillin
+-- Painless bright-red bleeding, age 2-10 -> polyp
+-- Prolapse -> reduce; treat stools; sweat test
+-- Infant perianal abscess -> drain; usually resolves

4. Dangerous Mimics

Table 14.3 — Paediatric mimics

5. Role-Targeted Action Boxes

🚑 ER DOCTOR ACTION BOX

• Redcurrant-jelly stool, colicky pain, and lethargy = intussusception until proven otherwise — urgent ultrasound and paediatric surgery.
• Avoid antimotility drugs in children with bloody diarrhoea (HUS risk).
• Safeguarding concerns are acted on in the ER, not deferred to “follow-up”.

🩺 FAMILY MEDICINE / GP CLINIC BOX

• Treat constipation adequately and for long enough — under-treatment is the commonest cause of failure.
• Swab a bright-red perianal rash before calling it candida.
• Recurrent rectal prolapse → sweat test.

🏥 ER & WARD NURSE CARE AND SBAR BOX

• Child-friendly approach: distraction, parent present, chaperone, explanation at the child’s level.
• Escalate safeguarding concerns to the named safeguarding lead the same day.

💊 CROSS-SPECIALTY PRESCRIBING TRAP

• Adult doses and adult drugs: check paediatric formulary doses by weight; avoid stimulant laxatives as the sole long-term therapy without specialist advice; mebendazole age restrictions.
• Topical steroids and GTN are not routine in children.

⛔ NEVER DO THIS

• Never force an anorectal examination on a child.
• Never perform a detailed forensic examination yourself when abuse is suspected.
• Never treat a bright-red perianal rash as candida without considering streptococcus.
• Never give antimotility drugs to a child with bloody diarrhoea.

📝 COMMON DOCUMENTATION ERROR

• Safeguarding notes without the child’s exact words, who was present, and the actions taken.
• Constipation notes without growth, meconium history, and neurological examination.

📨 REFERRAL URGENCY BOX

The Patient in Front of You — Chapter 14 Mini-Case

🧑‍⚕️ THE PATIENT IN FRONT OF YOU

A 5-year-old boy has had 3 weeks of painful defecation, blood streaks on the paper, and a red perianal rash treated as nappy rash with an antifungal cream. The rash is bright red, sharply demarcated, and tender, with no satellite lesions. His sister recently had a sore throat.

Step 1 Rethink the rash: sharply demarcated, painful, no satellite lesions, sibling with sore throat → perianal streptococcal dermatitis.

Step 2 Confirm: perianal swab for group A streptococcus.

Step 3 Treat: oral penicillin V or amoxicillin for about 10 days; stool softener for painful defecation.

Step 4 Follow up: review response; consider household contacts and recurrence.

Board-Style Question — Chapter 14

A 3-year-old girl has had three episodes of rectal prolapse after straining. She has frequent bulky, greasy stools and is below the 3rd centile for weight. Which investigation is most important?

• A. Barium enema
• B. Sweat chloride test
• C. MRI of the pelvis
• D. Anorectal manometry

Answer and explanation

• ❌ A A barium enema is not the priority.
• ✅ B Correct. Recurrent rectal prolapse with steatorrhoea and poor growth suggests cystic fibrosis; a sweat test (or the local CF diagnostic pathway) is essential.
• ❌ C MRI is not indicated.
• ❌ D Manometry does not address the likely underlying cause.

Ten-Item Rapid Revision Checklist — Chapter 14

• 01 I examine children with a parent and chaperone and do not force examination.
• 02 I treat functional constipation with macrogol disimpaction and maintenance.
• 03 I know the red flags for Hirschsprung disease and spinal causes.
• 04 I swab bright-red perianal rashes for streptococcus.
• 05 I treat threadworm in the whole household.
• 06 I refer painless bright-red bleeding in a child for colonoscopy.
• 07 I request a sweat test for recurrent rectal prolapse.
• 08 I recognise intussusception and HUS as emergencies.
• 09 I act on safeguarding concerns the same day.
• 10 I never perform a detailed forensic examination myself.

Five Most Dangerous Mistakes — Chapter 14

1. ⚠️ Missing intussusception by calling it gastroenteritis.
2. ⚠️ Treating streptococcal perianal dermatitis as candida for weeks.
3. ⚠️ Under-treating constipation and blaming the child for soiling.
4. ⚠️ Missing cystic fibrosis behind recurrent prolapse.
5. ⚠️ Failing to act on — or over-interpreting — anogenital findings when abuse is a possibility.

Suggested Figure and Table Captions for the Medical Illustrator — Chapter 14

• Figure 14.1. Child-friendly examination positions with parent and chaperone.
• Figure 14.2. Perianal streptococcal dermatitis versus candidal dermatitis.
• Figure 14.3. Age ladder of common and must-not-miss paediatric conditions.
• Table 14.1. Paediatric anorectal conditions.
• Table 14.2. Safeguarding indicators and actions.
• Table 14.3. Paediatric mimics.
• Algorithm 14.1. Child with an anorectal symptom.