Anorectal Pathology
Anal Fissure
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
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
Anorectal fistula
- Management
- Surgery
- Consider Crohn's
Perianal and perirectal abscess
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
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
References:
- AAFP 2012 http://www.aafp.org/afp/2012/0315/p624.html
- Hemorrhoids