Clinical Presentation & Protocol
Patient Usually Complains Of
Patient presents with complaints of intermittent protrusion of rectal mucosa during defecation, spontaneously reducing. Reports associated symptoms of mild perianal discomfort, mucoid discharge, and occasional pruritus. Denies fecal incontinence, significant bleeding, or pain at rest. No history of chronic constipation or straining.
Clinical Examination Findings
Digital Rectal Examination (DRE) and anoscopy performed. At rest, anal tone is within normal limits. Upon Valsalva maneuver, circumferential protrusion of the rectal mucosa (Grade I) is observed, extending <2 cm from the anal verge. No full-thickness prolapse or ulceration noted. Mucosa appears erythematous but intact. No evidence of hemorrhoidal disease or fissures.
Treatment Protocol
Conservative management initiated. Patient advised on high-fiber diet (25-30g/day) and adequate fluid intake to prevent straining. Pelvic floor physical therapy (biofeedback) recommended. Topical hydrocortisone cream prescribed for perianal irritation. Follow-up scheduled in 6 weeks to assess for symptomatic improvement.