Local anal conditions 

• Differentials to consider if cannot see any swelling – anal fissure, anal herpes, ulcertive proctitis, proctalgia fugax, solitary rectal ulcer, tenesmus
• Painful swelling – perianal haematoma, strangulated internal haemorrhois, abscess (perianal or ischiorectal), pilonidal sinus, fistula-in-ano(intermittent)
• Red flags for anorectal pain
  • Weight loss
  • Change in bowel habits
  • Fever
  • Recurrent (consider Chron’s)

Anal fissure

• Split in the skin of the anal canal
• Cause – often hard stool
• Clinical
  • Recent hard stool/constipation
  • Pain worse with defecation – can continue afterwards
  • Small volume blood PR
  • Appears similar to ulcer
  • 90% are posterior
• Differentials
  • Chron’s, infection, anal carcinoma
  • Consider other differentials if – lateral location, chronic > 8-12 weeks, recurrent, change in bowel habits, fever, or multiple fissures
• Complications – can have associated haemorrhoid or fistula
• Management
  • Acute
    • Avoid hard stool – stool softeners/bulk forming laxatives Warm salt baths after bowel motions
    • If needed glyceryl trinitrate ointment 0.2% (Rectogesic) TDS topcially insert into anal canal with gloved finger – to relax sphincter
    • Caution with hypotension if taken sildenafil
    • Oral or topical Ca channel blocker is alternative
  • For pain relief
    • Combination steroid/local anaesthetic – but shouldn’t have prolonged use, can irritate skin, not recommended by EtG
• Chronic fissure
  • Specialist advise
  • Consider local injection botulinum
• Surgery – lateral sphincterectomy

Haemorrhoids (piles)

• Enlarged, displaced anal submucosal vascular networks
• Downward pressure during defecation, damages supporting fibromuscular tissue, become more congested and then prolapse
• Causes – constipation, chronic straining, passage hard stool, increased abdominal pressure (chornic cough, pregnancy), prolonged sitting, hereditary, low fibre diet
• Symptoms internal hemorrhoids
  • Bleeding – typically small volume, bright red, on toilet paper
  • pain, itching, prolapse, soilage
  • Perianal discomfort + pruritis
  • PR mucus discharge
  • If uncomplicated, should NOT cause pain but thrombosed/strangulated will
• External hemorrhoids usually don’t cause symptoms unless thrombosis (perianal haematoma)
• Differentials – anal fissure, rectal prolapse, rectal polyp, colorectal Ca, IBD, perianal skin lesions
  • Consider colonoscopy if > 50 or family history CRC or abnormal pattern of bleeding/other red flags
• Examination
  • Assess anal canal / perianal region
  • Classically in 3, 7 and 11 o’clock positions.
  • DRE to exclude other local disease
    • Severe pain may suggest abscess or fistula
  • Anoscopy/proctoscopy recommended to visualize if internal

Grading External/internal + degrees if external.

Internal: Dilation of superior haemorrhoidal plexus.

External: Dilation of inferior haemorrhoidal plexus – below dentate line. 

🡪 Graded by degrees:

1. Small, bleeds, but remains in rectum
2. Prolapse on straining, retract spontaneously
3. Prolapse on straining, require manual replacement
4. Prolapse spontaneously, despite attempts to replace

• Treatment
  • Adequate fluid and fibre intake – avoid constipation
  • Avoid straining
  • Respond to urge to defecate – try not to initaite/push without the urge
  • Topical
    • No evidence that OTC local anaesethic/steroid/antiseptic help disease
    • Emmolients and mild astringents may help to relieve itch/discomfort
    • Topical lidocaine may help pain
    • 0.3% nifedipine + lidocaine may improve resolution if thrombosed

□  Preferred to GTN less headaches

• May contain local anaesthetic/steroid – avoid prolonged use – skin sensitisation

• Warm bath
• Rubber band ligation if persistent bleeding
• Other local therapies – sclerotherapy, infrared coagulation
• Surgery if cannot be reduced, persistent symptoms or associated skin tags
• If develop during pregnancy usually resolve after delivery

Perianal haematoma

• Aka – thrombosed external hemorrhoid
• Painful tense blue/purple swelling at anal margin
  • Thrombosis of a ruptured vein
• Will resolve spontaneously over 1-2 weeks
• If severe can excise or drain under local anesthesia

Strangulated hemorrhoid

• Treat with rest and ice packs and then refer for hemorrhoidectomy

Anorectal abscess and fistula

• common in Chron’s disease, but most patients will not have another cause
• If have Crohn’s disease – refer surgeon, may be treated metronidazole or ciprofloxacin for weeks/months

Perianal abscess

• Caused by infection of anal glands that drain anal canal at the dentate line
• Perianal most common, but can be deeper anorectal abscess – may have increased pain
• Symptoms
  • Perianal pain – not typically associated with defection
  • Pain is severe, throbbing, constant
  • Swelling adjacent to anal margin
• Requires urgent surgical drainage
• Adjunct antibiotics
  • mild treat with oral augmentin
  • Severe treat – Gentamicin, Metronidzaole, amox/ampicillin
  • (as per diverticulitis guideline)

Ischiorectal abscess

• Larger, more diffuse bulky dusky red swelling in the buttock
• Needs incision and drainage

Anorectal fistula

• Abnormal communication between anorectum and perianal skin
• Complication of abscess
• Surgery to determine anatomy, drain abscess, lay open fistula whilst maintain continence

Pinworms/ Threadworms

• Enterobius vermicularis, lay eggs in the anus at night
  • Children swallow eggs – hatch in small intestine
• Common in children
• Clinical
  • Itchy anus
  • Irritable
  • Can cause/worsen vulvovaginitis
  • Thread worm may be visible at night
• Not usually associated with other helminths
• Investigation
  • Not always required
  • Can do sticky tape test collection to confirm
  • Consider stool testing for other infections
• Treatment
  • Mebendazole or pyrantel – single dose, avilable OTC
  • Albendazole- single dose, needs prescription
  • Consider repeating dose 2 weeks later – frequently reinfects
  • Treat household contacts
  • Hygiene – hand washing, avoid scratching, fingernails short, shower daily, wash clothing/towels/linen in hot water

Hook worm

• Acquired from walking barefoot
• Same treatment as threadworm

Proctalgia fugax

• Episodic, short attacks of intense stabbing or cramping pain
• 3- 30 mins
• Often wakes from sleep
• No pain between episodes
• affects patients between 30 and 60 years of age
• is a diagnosis of exclusion
  • Other causes of anorectal pain (e.g., hemorrhoids, cryptitis, ischemia, abscess, fissure, rectocele and malignant disease)
• Unknown cause – ?spasm of pelvic floor/levator ani. Functional bowel disorder
• More common in women
• Management
  • Explain
  • Reassure brief and self limiting
  • Local warmth
  • Immediate ingestion of food or drink
  • Firm pressure to perineum
  • If severe may trial – inhaled salbutamol, antispasmodic drugs, calcium channel blockers, clonidine, GTN

Pruritis Ani

• Itching of perianal skin
• Persistent scratching can cause lichenification
• Assocaited with dermatitis, posirasis, lichen planus
• Can be aggravated by lack of hygiene, fecal incontinence, wiping
• Differentials
  • Skin disease
  • Anal pathology – fissure, skin tag, haemorrhoids, fistulas, wart
  • Crohns disease, perianal intraepithelial neoplasia
  • Threadworm, streptococcal perianal dermatitis in child
• Treatment
  • Clean gently with moist cotton wool
  • Soap substitute
  • Greasy emollient
  • Bulkier stool
  • Loose fitting cotton underwear
  • Consider treating infection if skin weeping/ulcerated. N.b. Candida is not a cause
  • If not treatable cause – methylprednisone aeptonate 0.1% fatty ointment topically until itch cleared, up to 4 weeks
  • Continue general measures indefinitely

Perianal cellulitis

• Strep pyogenes in pre-school and school age children
• Acute perianal redness and pain with defection
• Frequently relapses
• Treat any co-existing constipation or anal fissure
• Treatment
  • Cephalexin (often doesn’t respond to penicillins)

Perianal warts

• Podophyltoxin
• Cryotherapy
• Aldara/ Imiquimod 3 times weekly