Common Anorectal Conditions

Garrett MeyersFaculty Development Fellow

Objectives

• Explored visual diagnosis of common

benign anorectal conditions

• Discussed optimal management strategies

Clicker Check

A. I am a medical student

B. Resident

C. Staff

D. Other

When do we need to refer?

Case #1

A 38 year old male presents to your clinic complaining of 2 months of

anal pruritus, intermittent bright red blood noted on the toilet paper,

and pain.

Which statement is false concerning this patient?

A. Excision is likely to be of benefit

B. Conservative measures should be initiated

C. Fiber supplementation is associated with improvement

D. Topical analgesics are indicated

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Your Treatment Plan

What is “conservative” therapy?

Conservative Therapy

• Sitz Baths

• Stool softeners

• Fiber supplementation

• Topical therapy

Which statement is false concerning this diagnosis?

A. Hemorrhoidectomy benefit drops after 72 hours

B. Conservative management is unlikely to be of benefit

C. Malignancy may be comorbid

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0

62 year old male referred for colonoscopy for persistent bleeding despite conservative treatment.

Which statement is false concerning this diagnosis?

A. This diagnosis is the most common cause of rectal bleeding

B. Rubber band ligation is the most effective treatment

C. Surgical excision has better remission rates for grade 3 and higher

D. Excision is associated with decreased pain and complications

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Case #2

A 38 year old female presents to your clinic complaining of over one year of anal itching. She has worked to self-

manage without success.

Which statement is false concerning pruritus ani?

A. It has a broad differential diagnosis

B. It may be radicular in nature

C. Topical steroids should be avoided

D. Antibacterial soap is effective

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Case #3

A 26 year old male presents complaining of anal pain. He notes

constipation, with recent BM’s including a feeling of passing “shards of glass.” He notes small bright red

blood after BM’s.

Case #3

Diagnosis?

A. Anal Fissure

B. Hemorrhoid

C. Fistula-in-ano

D. Abscess

E. Proctitis

Which fissure therapy has not been shown to be effective?

A. Conservative measures

B. Topical sildenafil

C. Topical nitroglycerin

D. Botox

E. Topical diltiazem

Which requires referral?

A. Chronic fissure

B. Non-midline fissure

C. Fissure with chronic constipation

D. Adjacent skin tag

Case #4

23 year old AD male with a painful anal mass

Diagnosis?

A. Anal Fissure

B. Hemorrhoid

C. Fistula-in-ano

D. Abscess

E. Proctitis

Which is a true statement for this diagnosis?

A. Antibiotics are necessary

B. Conservative therapy will lead to resolution

C. This diagnosis requires referral

D. Acute onset with minimal exam findings is concerning

Case #5

23 year old male with a

painless anal mass.

Which is false concerning this diagnosis?

A. No topical treatment has been shown to have superior efficacy

B. Anoscopy should be performed

C. Biopsy for persistence

D. Home treatment is not recommended

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Case #6

A 26 year old male presents complaining of anal pain, occasional

discharge, and a sensation of swelling.

Case #6

Diagnosis?

A. Anal Fissure

B. Hemorrhoid

C. Fistula-in-ano

D. Abscess

E. Proctitis

Which is true regarding treatment?

A. All fistulas should be referred for surgical evaluation

B. MRI or ultrasound may help define the lesion

C. Posterior position is concerning

D. Abscess formation is uncommon

62 year old female with a complaint of recent constipation, straining, and an

anal mass.

28 year old male with nocturnal diarrhea and chronic weight loss.

What is the most important piece of advice for this patient?

27 year old male with recent rectal pain, intermittent bloody stools, urgency, tenesmus,

and lower abdominal pain.

A 52 year old male presents with sudden onset anal pain which lasts for several seconds up to minutes.

It often occurs at night. He is unable to identify a trigger.

Exam is unremarkable except for increased anal sphincter tone.

Take-home points

• Consider malignancy

• Know, use, love conservative measures

Questions