What disorder of the anus or rectum best fits this presentation?
A 22-year-old nurse comes to your clinic, complaining of severe constipation and pain during defecation. She has also seen blood on the toilet paper. She states that she eats a healthy diet and does some light exercising. She is currently at the beginning of her third trimester of an unremarkable pregnancy. Her past medical history is unremarkable. Her mother has high cholesterol but her father is in good health. She does not smoke, drink alcohol, or use illegal drugs. She is married and expecting her first child. On examination she appears healthy and is afebrile, with a blood pressure of 110/60. Her abdominal examination reveals a gravid uterus but is otherwise unremarkable. On visualization of the anus there is a slight red, moist-appearing protrusion from the anus. As you have her bear down, the protrusion grows larger. On digital rectal examination you can feel an enlarged tender area on the posterior side. There is some blood on the glove after the examination.
A) Anal fissure
B) External hemorrhoids
C) Internal hemorrhoids
D) Anorectal fistula
C) Internal hemorrhoids
Internal hemorrhoids are common during pregnancy. A red, swollen, moist mass is seen prolapsing through the anus, which worsens with bearing down. These are not usually palpable on rectal examination if not prolapsed.
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