A detailed and well-collected medical history can provide a diagnosis by itself for many coloproctologic disorders. Initiating the interview following a “symptom-based” approach is advisable in order to relax and put at ease the patient before performing the anorectal examination. Embarrassment does not help the patient when explaining symptoms, therefore directing questions is helpful (Table 13.2).

Anal pain. When visiting a patient with anal pain, it is important to investigate the localization (inside or around the anus), chronology (acute pain or chronic pain), the pain characteristics (intermittent or constant), if it is associated with bowel movements, and especially if those worsen or improve the pain. Association with other clinical conditions such as constipation, diarrhea, bleeding, mucus or purulent anus discharge, perianal mass, or tenderness and systemic symptoms like fever must be investigated too. The differential diagnosis for anal pain includes perianal abscesses, anal fissure, thrombosed external hemorrhoid, chronic proctalgia (levator ani syndrome), and proctalgia fugax, among others.

Rectal bleeding. Any kind of rectal bleeding must be considered seriously until cancer is ruled out. Investigation should focus on the starting point, if it is continues or intermittent, occasional or frequent. The patient should also be interrogated about its relationship with bowel movements. The color of the blood, if the blood forms clots, drips in the toilet after defecation, paints the stools, or stains the toilet paper are important questions that the physician should ask. Associated symptoms such as constipation of new onset, diarrhea, mucous discharge from the anus, anal pain during defecation, rectal tenesmus, asthenia, abdominal pain or discomfort, and recent history of nonvoluntary weight lost must be investigated. The age, significant family history of bowel disease or cancer, and persisting bleeding in spite of previous treatment are to be considered during the diagnostic process. Differential diagnosis for rectal bleeding must consider benign conditions such as hemorrhoids, anal fissure, rectal prolapse, rectal solitary ulcer and colorectal polyps, as well as malignancies.

Perianal itching. Perianal itching or burn sensation in the perianal area is a very commonly reported symptom. Since perianal itching is associated with a wide range of mechanical, infectious, dermatologic, hygienic, and systemic conditions, it is of great importance to approach patients collecting an accurate anamnesis, general and specific, although some cases turn out to be idiopathic (pruritus ani). First of all, it is essential to know if dealing with a chronic problem or one of recent onset, if it is constant during the day, at night, or intermittent, and investigate its intensity (continuous need to scratch and/or does not permit sleeping). Given that causes of itching could be related to bowel movement, the presence of diarrhea must be investigated, as well as the sensation of seepage or moisture around the anus, mucous soiling, or fecal incontinence. It is important to ask patients about their intimate hygienic habits because those can be related to overcleaning of the perianal area with soap, frequent scrubbing, as well as direct application of certain types of soap, perfume, and other irritant cosmetic agents on or around the anus. Because certain substances like cola, coffee, citric foods or drinks, chocolate, and calcium have been found to be potentially related to pruritus ani, any abuse of these foods should be investigated. Medication for other pathologies like certain chemotherapy, colchicine, and quinidine as well as topical use of corticoids in perianal cutaneous area have also been related to anal itching, thus its use should be included in the interrogatory.

Fecal incontinence. Normal continence depends on the balance between consistency of the stool (chronic diarrhea or liquid stool), anal sphincter function and/or its integrity, and the normal central and peripheral nervous system regulation. The approach to patients referring fecal continence problems must be global, so systemic nervous illnesses, diabetic neuropathy, and previous complex pelvis injuries must be ruled out. Before making a choice among the different diagnostic tools that we can use to better define our patient’s incontinence level, the anamnesis is going to be, once again, crucial. We need to know when the problem started, if the patient is capable of controlling gas, as well as liquid and solid fecal stool. Frequency of the episodes of incontinence (occasionally or daily) and the need for diaper use should be investigated. The Wexner (Jorg and Wexner 1993) and Vaizey score (Vaizey et al. 1999) and the creation of a defecation diary are both tools of great use as they allow to have a better knowledge on how incontinence affects the patient quality of life and, therefore, helps with the design of the best diagnostic-treatment schema. Any possible triggers such as recent coloproctologic and gynecologic surgery, pelvic radiation, and pelvic and anal injuries must be investigated. A thorough obstetric medical history must always be collected, as a lesion to the sphinteric complex or the pudendal nerves may have occurred during delivery and might contribute to the incontinence. Association with other symptoms such as urinary incontinence, rectal and genital prolaps, pelvic and anal pain, new-onset constipation, and rectal tenesmus must be taken into consideration in the differential diagnosis between idiopathic or secondary fecal incontinence.