The prevalence of benign anorectal conditions in the primary care setting is high, although evidence of effective
therapy is often lacking. In addition to recognizing common benign
anorectal disorders, physicians must maintain a high index of suspicion for inflammatory and malignant disorders. Patients with red flags such as increased age, family history, persistent anorectal
bleeding despite treatment,
weight loss, or
iron deficiency anemia should undergo colonoscopy.
Pruritus ani, or perianal
itching, is managed by treating the underlying cause, ensuring proper hygiene, and providing symptomatic relief with oral
antihistamines, topical
steroids, or topical
capsaicin. Effective treatments for anal fissures include
onabotulinumtoxinA, topical
nitroglycerin, and topical
calcium channel blockers. Symptomatic external
hemorrhoids are managed with
dietary modifications, topical
steroids, and
analgesics. Thrombosed
hemorrhoids are best treated with
hemorrhoidectomy if symptoms are present for less than 72 hours. Grades I through III internal
hemorrhoids can be managed with rubber band
ligation. For the treatment of grade III internal
hemorrhoids, surgical
hemorrhoidectomy has higher remission rates but increased
pain and complication rates compared with rubber band
ligation. Anorectal condylomas, or anogenital
warts, are treated based on size and location, with office treatment consisting of topical
trichloroacetic acid or
podophyllin,
cryotherapy, or
laser treatment. Simple anorectal
fistulas can be treated conservatively with sitz
baths and
analgesics, whereas complex or nonhealing
fistulas may require surgery.
Fecal impaction may be treated with
polyethylene glycol,
enemas, or manual disimpaction.
Fecal incontinence is generally treated with
loperamide and
biofeedback. Surgical intervention is reserved for anal sphincter injury.