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