Condition		Historical clues	Examination findings	Treatment
Pruritus ani^3-8		Excessive hygiene, poor hygiene, dietary irritants, contact irritants, skin conditions, systemic disease, sexual history	Lichenification, excoriation, erythema, intertrigo, prolapsed hemorrhoid, inflamed skin tag, fecal soilage, condyloma (anogenital wart), chronic fissure, fistula	Underlying cause, hygiene education, antihistamine, weak topical steroid, antibacterial soap, capsaicin 0.006% cream
Anorectal pain
	Anal fissure^9-13	Sudden onset, feeling of passing “shards of glass,” occurs during bowel movement, small amount of bright red blood in stool	Acute: sharp edges Chronic: indurated, sphincter fibers at base, sentinel skin tag or polyp	Topical nitroglycerin 0.2% ointment, onabotulinumtoxinA (Botox), topical calcium channel blocker, topical bethanechol, sitz baths, stool softeners, fiber, topical analgesics
	Proctalgia fugax^14–18	Sudden onset, no trigger, transient, occurs at night	Increased internal anal sphincter tone, otherwise unremarkable examination	Benzodiazepines, onabotulinumtoxinA, intravenous lidocaine (Xylocaine) infusion, sacral nerve stimulation, pudendal nerve block
	Proctitis¹⁹	Human immunodeficiency virus/AIDS, inflammatory bowel disease, history of radiation treatment or ischemia, urgency, tenesmus, abdominal pain	Tenderness on rectal examination	Treat underlying cause
	Thrombosed hemorrhoid²⁰	Bleeding, pain, constipation	Swollen, erythematous external hemorrhoid	Hemorrhoidectomy if symptoms are present less than 72 hours; sitz bath if symptoms are present for 72 hours or more
Anorectal mass
	Abscess²¹	Drainage of pus, tender mass	Swelling	Incision and drainage
	Condyloma (anogenital wart)^22,23	Other sexually transmitted diseases, itching, bleeding, mass	Warts on visual inspection, vaginal speculum examination, or anoscopy	Large lesions: surgical referral Smaller lesions: office treatment with trichloroacetic acid, podophyllin, laser treatment, or cryotherapy; home treatment with imiquimod (Aldara) or podophyllotoxin
	Rectal prolapse	Postmenopausal, constipation, weakened pelvic support	Complete protrusion of all rectal layers through anus, cystocele, rectocele, vaginal prolapse	Surgical repair
Anorectal fistula^21,24,25		Pain; discharge; swelling; bleeding; history of Crohn disease, obstetric trauma, or radiation therapy	Discharge, open sinus, granulation tissue, palpable cord	Conservative treatment for simple fistula; complex fistula usually requires referral to a surgeon
Hemorrhoids^26-31		Bleeding, pain, pruritus	Anal mass	Increased fiber and fluid intake External hemorrhoids and internal grade I hemorrhoids: topical steroids and analgesics Internal grade I through III hemorrhoids: rubber band ligation, sclerotherapy, infrared coagulation Internal grade III or IV hemorrhoids: hemorrhoidectomy
Fecal impaction^32,33		Straining, abdominal pain, constipation, overflow incontinence, hard stools	Palpable abdominal mass or hard stool on digital rectal examination, stool on abdominal radiography	Polyethylene glycol (Miralax), enemas, suppositories, manual disimpaction
Fecal incontinence^34-37		Hard stools (overflow incontinence), neurologic disease (dementia, lumbar disk herniation)	Stool impaction, rectal prolapse intussusception (suggesting rectosphincteric disorder), decreased rectal tone	Dietary modification, bulking agents, antidiarrheal agents (e.g., loperamide [Imodium]), repair of anal sphincter, biofeedback