Pearls:

Patients who are immunocompromised or toxic appearing and present with symptoms of perianal abscess should be evaluated for deep post-anal abscess.

Fissures outside of the 6:00 position require specialist follow up because they are more likely to be representative of a systemic disease such ulcerative colitis, Crohn's, HIV, tuberculosis or malignancy.

HEMORRHOIDS

Are not painful because they are made of rectal mucosal epithelium which only has a visceral innervation.

Can be visualized on simple inspection of the anus.

They are painful because they are made of squamous epithelium, which is innervated.

Distal to the dentate line at the anal verge.

Conditions that increase straining and pressure on the venous plexus can cause hemorrhoids.

Hemorrhoids are usually caused by constipation and lack of dietary fiber

Patients often report blood on the toilet paper or a small amount of blood in the toilet bowl.

The most common cause of rectal bleeding that we see in the Urgent Care setting.

Complications of thrombosed hemorrhoids are rare and include uncontrolled bleeding, abscess, fistula formation, infection and ischemic hemorrhoids.

If the patient does not wish to have the thrombosis excised or the thrombosis has been present for > 48 hours, treat medically and arrange for follow up with colorectal surgery.

If a patient presents within the first 48 hours after thrombosis it can be excised in the UC setting.

External hemorrhoids that become painful and irritated are likely thrombosed.

Add a laxative or stool softener to relieve constipation or immodium to prevent diarrhea.

Sitz baths are the mainstay hemorrhoid management. Instruct patients to sit in a bath of warm water with salt added several times a day.

ANAL FISSURES

Consider sexual abuse in children who present with fissures.

Fissures located anywhere but the 6:00 position in men and women who are not postpartum require specialist follow up because this could be secondary to a another condition such ulcerative colitis, Crohn's, HIV, tuberculosis or malignancy.

The treatment for anal fissures includes all of the same treatments for hemorrhoids (see above) as well as calcium channel blockers that relax smooth muscle and prevent spasm.

The 6:00 position is most common in both men and women.

Fissures occur commonly in postpartum patients at the 12:00 (anterior towards perineum) and the 6:00 (towards the back) position.

The most common presentation will be pain with bowel movements.

Fissures are a tear in the skin below the dentate line that extends distally to the anal verge.

CRYPTITIS

Treatment includes the same medical therapies for patients with hemorrhoids.

Visualization with the anoscope is required which will demonstrate a small amount of pus or inflammation in the crypts at the dentate line.

Will have some localized tenderness on digital rectal exam.

Present with anal pain, spasm and sometimes itching or bleeding.

Inflammation of the pockets between the columns of Morgagni at the dentate lines.

ANORECTAL ABSCESS

Refer to an emergency department for advanced imaging and surgical consultation.

Consider deep postanal abscess when the patient is immunocompromised or ill appearing especially if unable to visualize an abscess exam.

Postanal abscesses extend upward, through the different layers of musculature and connect the ischiorectal fossa bilaterally.

The treatment of both perianal abscesses and ischiorectal abscesses is incision and drainage with or without antibiotics depending on the presence of surrounding cellulitis and if the patient is ill appearing.

Ischiorectal abscesses present as a tender, fluctuant mass on the buttocks itself.

Perianal abscesses begin as infected crypts that extend downward towards the anal verge, from the dentate line. They appear as a superficial tender mass close to the anal verge which may or not be fluctuant.

ANAL FISTULA

Fistulas began as abscesses that then tunnel either externally into the buttocks or internally into the rectum.

Fistulas present with chronic purulent drainage or malodorous discharge usually in patients who have an underlying condition such as Crohn's disease, ulcerative colitis, cancer or previously had radiation therapy to the perineum.