Benign Anorectal Conditions: Evaluation and Management

 

Common anorectal conditions include hemorrhoids, perianal pruritus, anal fissures, functional rectal pain, perianal abscess, condyloma, rectal prolapse, and fecal incontinence. Although these are benign conditions, symptoms can be similar to those of cancer, so malignancy should be considered in the differential diagnosis. History and examination, including anoscopy, are usually sufficient for diagnosing these conditions, although additional testing is needed in some situations. The primary treatment for hemorrhoids is fiber supplementation. Patients who do not improve and those with large high-grade hemorrhoids should be referred for surgery. Acutely thrombosed external hemorrhoids should be excised. Perianal pruritus should be treated with hygienic measures, barrier emollients, and low-dose topical corticosteroids. Capsaicin cream and tacrolimus ointment are effective for recalcitrant cases. Treatment of acute anal fissures with pain and bleeding involves adequate fluid and fiber intake. Chronic anal fissures should be treated with topical nitrates or calcium channel blockers, with surgery for patients who do not respond to medical management. Patients with functional rectal pain should be treated with warm baths, fiber supplementation, and biofeedback. Patients with superficial perianal abscesses not involving the sphincter should undergo office-based drainage; patients with more extensive abscesses or possible fistulas should be referred for surgery. Condylomata can be managed with topical medicines, excision, or destruction. Patients with rectal prolapse should be referred for surgical evaluation. Biofeedback is a first-line treatment for fecal incontinence, but antidiarrheal agents are useful if diarrhea is involved, and fiber and laxatives may be used if impaction is present. Colostomy can help improve quality of life for patients with severe fecal incontinence.

Anorectal conditions are commonly seen in primary care settings.1 Although the differential diagnosis is broad, a history coupled with an external examination (with and without straining), a digital rectal examination, and anoscopy can often provide the correct diagnosis.2  This article focuses on common benign anorectal conditions (Table 1215), but clinicians must keep in mind that benign and malignant diseases often present with similar symptoms.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationsEvidence ratingComments

Dietary modification including adequate fiber intake improves quality of life and is recommended in the treatment of multiple benign anal conditions including hemorrhoids, anal fissures,functional rectal pain, and fecal incontinence.9,58,61

B

Two smaller RCTs and a prospective observational trial showing symptom benefit in several different conditions

Along with dietary modification, topical treatments such as flavonoids, steroids, analgesics, and antiseptics may be used to treat hemorrhoids.2,19

C

Expert opinion and consensus guidelines in the absence of clinical trials

In addition to measures aimed at softening the stool, chronic anal fissures should be treated with topical nitroglycerin 0.4% ointment, topical calcium channel blockers, or onabotulinumtoxinA (Botox) injections.21,3537

A

Multiple meta-analyses, including a Cochrane review, showing symptom benefit and resolution of fissures

Manual stretching should not be used to treat anal fissures.39

A

Meta-analysis of four RCTs showing less effectiveness and more complications compared with other treatments

Patients with fecal incontinence should be referred for biofeedback.5,60

B

Two RCTs with consistent data showing improved symptoms and quality of life


RCT = randomized controlled trial.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to https://www.aafp.org/afpsort.

The Authors

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MARK W. COHEE, MD, is the assistant program director and an assistant professor in the Department of Family Medicine at the University of Virginia School of Medicine, Charlottesville....

ASHLEE HURFF, MD, is a third-year resident in the Department of Family Medicine at the University of Virginia School of Medicine.

JOHN D. GAZEWOOD, MD, MSPH, FAAFP, is the director of the Family Medicine Residency Program and an associate professor of family medicine at the University of Virginia School of Medicine.

Address correspondence to Mark W. Cohee, MD, University of Virginia, 1221 Lee St., Charlottesville, VA 22908 (email: mc6rc@hscmail.mcc.virginia.edu). Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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