W John Daniel
Anorectal problems are frequent presentations in the general practice setting.1 Symptoms tend to be a combination of one or more of pain, lumps, bleeding, discharge or itch. In this article we focus on pain, lumps and bleeding. (Perinanal itch is discussed in the article by MacLean and Russell in this issue).
The patient presenting with anal pain, anal lump or rectal
bleeding is a common occurrence in the general practice
setting and the combination of symptoms usually gives an
indication of the most likely diagnosis. However, careful
examination including digital rectal examination is always
This article discusses three common anorectal conditions:
perianal haematoma, haemorrhoids and anal fissure, and
briefly discusses the less common, but not to be missed
conditions: anal carcinoma and low rectal carcinoma.
The majority of first degree haemorrhoids can be
managed by conservative measures alone. More severe
degree haemorrhoids require surgical intervention with
sclerosant injection, rubber band ligation or surgical
haemorrhoidectomy. Initial treatment for anal fissure
is with a high fibre diet, faecal softeners, topical local
anaesthetic gel and glycerol trinitrate ointment. Botulinim
toxin can be injected to create a chemical sphincterotomy,
allowing healing. Chronic fissures produce intense and
constant pain in the anal region and in these cases surgical
sphincterotomy is often necessary to cure the condition,
but can result in faecal incontinence. Anal cancer has
similar presentation to haemorrhoids and carcinoma of
distal rectum can initially present with a haemorrhoid, so
the possibility of anorectal cancer should be considered in
any patient presenting with haemorrhoids, tenesmus and
change in bowel habit.
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