Anorectal Pathology

Anal Fissure

  • Conservative management
    • Diet with adequate fluid (eg. 6-8 cups of water/day) and fiber (eg. 25-30g/day, supplement with psyllium 1-3 tablespoons daily, increase until stools are regular and soft)
    • Warm Sitz baths TID and avoid straining
  • Medical management
    • Xylocaine ointment 5% QID PRN
    • Nifedipine 0.2% ointment BID-QID (compounding pharmacy) PRN
    • Nitroglycerin 0.2% or 0.4% rectal ointment BID (Rectiv)
      • Avoid with PDE5 inhibitors
      • Risk of hypotensions/dizziness with both
    • Refer if suspicious of Crohn's (eg. if not single posterior/anterior, or perianal findings)
    • Refer if not improved by 4-8 weeks

Thrombosed external hemorrhoid

  • Conservative management
    • Diet with adequate fluid and fiber and Sitz baths
  • Medical management
    • Topical Hydrocortisone 1% ointment daily + Lidocaine 2% ointment up to 6 times daily
    • Acetaminophen/NSAIDs PO
    • Consider topical nitroglycerin/nifedipine ointment
    • Consider excision if <72h and severe pain

Anorectal fistula

  • Management
    • Surgery
    • Consider Crohn's

Perianal and perirectal abscess

  • Management
    • Incision and drainage (as close to anal verge as possible to minimize potential fistula that occur in 25% of cases)
    • No packing required
    • Consider antibiotics in immunosuppressed
    • Refer if ischiorectal (far from anal verge) or signs that may be deeper

Proctalgia fugax

  • Rule out other anorectal disease
  • Infrequent attacks of severe anorectal pain usually lasting less than five minutes
  • Reassurance, if severe frequent can consider topical nitroglycerine or diltiazem