A 40-Year-Old Man Comes to the Office with Pain on Defecation

A 40-year-old man comes to the office with pain on defecation.  The pain is sharp and severe but subsides within minutes of passing the bowel movement.  He often sees spots of bright red blood on the toilet paper.  The patient has chronic constipation and has not taken laxatives or increased his fluid intake to compensate.  He has no fever, night sweats, diarrhea, or unexpected weight loss.  Past medical history is notable for chronic low back pain following a motor vehicle accident, for which he takes a scheduled dose of pain relievers.  The patient has smoked a pack of cigarettes daily for the last 20 years but does not use alcohol or illicit drugs.  He is married and has no outside sexual contacts.  Vital signs are normal.  The abdomen is soft and nontender with no hepatosplenomegaly.  Rectal examination is likely to show a tear at which of the following locations?

A) Anterior midline distal to the dentate line
B) Anterior midline proximal to the dentate line
C) Bilateral distal to the dentate line
D) Lateral distal to the dentate line
E) Lateral proximal to the dentate line
F) Posterior midline distal to the dentate line

Correct Answer:

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