Anorectal Disorders

  • Defecatory disorders present with difficulty evacuating stool from the rectum or outlet constipation. The diagnosis is ideally made in the setting of compatible symptoms and abnormal testing, including DRE, balloon expulsion testing, barium defecography, MRI, anorectal manometry, and/or pelvic floor electromyography.1 Management includes biofeedback therapy, laxatives, and suppositories/enemas.2
  • Thrombosed external hemorrhoids present as acutely painful, tense, bluish lumps covered with skin in the anal area. The thrombosed hemorrhoid can be surgically excised under local anesthesia for relief of severe pain. In less severe cases, oral analgesics, sitz baths (sitting in a tub of warm water), stool softeners, and topical ointments may provide symptomatic relief.3
  • Internal hemorrhoids commonly present with either bleeding or a prolapsing mass with straining. Bulk-forming agents such as fiber supplements are useful in preventing straining at defecation. Sitz baths and witch hazel pads may provide symptomatic relief. Ointments and suppositories that contain topical analgesics, emollients, astringents, and hydrocortisone (e.g., Anusol HC Suppositories, one per rectum bid for 7–10 days) may decrease edema but do not reduce bleeding. Hemorrhoidectomy or band ligation can be curative and are indicated in patients with recurrent or constant bleeding.3
  • Anal fissures present with acute onset of pain during defecation and are often caused by hard stool. Anoscopy reveals an elliptical tear in the skin of the anus, usually in the posterior midline. Acute fissures heal in 2–3 weeks with the use of stool softeners, oral or topical analgesics, and sitz baths. The addition of oral or topical nifedipine to these conservative measures can improve pain relief and healing rates.4
  • Perirectal abscess commonly presents as a painful induration in the perianal area. Patients with IBD and immunocompromised states are particularly susceptible. Prompt drainage is essential to avoid the serious morbidity associated with delayed treatment. Antimicrobials directed against bowel flora (metronidazole, 500 mg PO tid, and ciprofloxacin, 500 mg PO bid) should be administered in patients with significant inflammation, systemic toxicity, or immunocompromised states.


  1. Rao SS, Bharucha AE, Chiarioni G, et al. Functional anorectal disorders. Gastroenterology. Published online 2016.
  2. Rao SS, Benninga MA, Bharucha AE, et al. ANMS-ESNM position paper and consensus guidelines on biofeedback therapy for anorectal disorders. Neurogastroenterol Motil. 2015;27:594-609.  [PMID:25828100]
  3. Davis BR, Lee-Kong SA, Migaly J, et al. The American society of colon and rectal surgeons clinical practice guidelines for the management of hemorrhoids. Dis Colon Rectum. 2018;61:284-292.  [PMID:29420423]
  4. Stewart DB, Gaertner W, Glasgow S, et al. Clinical practice guideline for the management of anal fissures. Dis Colon Rectum. 2017;60:7-14.  [PMID:27926552]


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