Symptom	Differential diagnosis	Key points
Anal bleeding	Anal fissures Anal polyps Hemorrhoids Upper or lower gastrointestinal tract bleeding	Hemorrhoids are the most common cause and often resolve with fiber supplementation; grade III and IV hemorrhoids are more likely to benefit from surgical therapies Evaluate for malignancy in patients 50 years and older who have not had screening per U.S. Preventive Services Task Force guidelines2–4
Incontinence	Fecal impaction Fistula Neurologic disease Rectal prolapse Sphincter defect	If etiology is unknown after history and examination, anal sphincter imaging may aid with the diagnosis; biofeedback is an effective treatment5,6
Mass	Abscess Anal polyps Condyloma Hemorrhoids Pilonidal cysts Rectal prolapse	Topical therapies are often effective for condyloma, but patients with large condylomata or those not initially responsive to treatment should be referred for surgical removal7,8
Pain	Abscess Anal fissures Fistula Proctalgia fugax Proctitis Rectal prolapse Thrombosed external hemorrhoids Unspecified functional rectal pain	Surgery is generally recommended for abscesses, fistulas, prolapse, and thrombosed hemorrhoids (within 72 hours of symptoms); anal fissures may benefit from conservative treatment in the first 12 months2,3,9–12
Pruritus	Dermatologic condition Excessive hygiene External hemorrhoids Infection Medication Pruritus ani	Topical hydrocortisone can be effective for pruritus ani; skin biopsy should be considered for patients without a clear etiology13–15