A sore bottom

This patient was referred for a flexible sigmoidoscopy because of PR bleeding. However, the only abnormality found was a sore anal canal.  Samples are taken of course. 
HOW WOULD YOU NOW ADVICE THE PATIENT?

■ We'll see you in clinic once histology is to hand

But there is a degree of urgency here!

■ Symptoms may improve with 'anusol'

No they will not!

■ We will try topical mononitrate first

You are barking up the wrong tree!

■ We will organise a scan next

Yes, a rectal MRI revealed something important!

■ Inject 80mg of triamcolonone

You are missing the point!

explanation

Actually, this isn't a case of haemorrhoids or an anal fissure. Histology reported; " Within hyperkeratotic epidermis there are scattered individual highly atypical infiltrating malignant cells with frequent apoptosis and moderate clear cytoplasm.  There is no ulceration or significant inflammation."  

Actually, this is a case of Perianal Paget's disease, - a VERY rare condition!!!   You'll remember that a 'puckering' of the skin around the breast areola is associated with underlying breast cancer. This was first reported by Sir James Paget in 1874.  However, a few years later, the same phenomenon was described elsewhere, so called "extramammary Paget's disease".  In descending order of frequency, this has been described at; the skin of the vulva, perineal skin, perianal skin and the skin of the scrotum.  

Paget's disease, is usually NOT a primary cancer of the apocrine glands of the skin. It's almost always secondary to a nearby cancer of the rectum, anus or prostate.  In this particular case, further imaging revealed a nearby prostate cancer! !