Anal and perianal disorders

Abstract

Most anal diseases can be diagnosed by a careful history and examination. Management of haemorrhoids involves exclusion of more serious pathology, adequate explanation of the disorder, and dietary and defecatory advice; most do not require additional treatment. Outpatient procedures or surgical intervention can be required for more symptomatic cases. Anal fissures are initially managed with bulking laxatives and non-constipating analgesics; glyceryl trinitrate ointment is standard first-line treatment. Lateral internal sphincterotomy is indicated rarely for fissures that do not heal after pharmacological management, although it is associated with a small risk of impaired continence. Anal fistulae and abscesses represent extremes of a single disease spectrum. Perianal abscesses should be treated by prompt adequate surgical drainage. Low fistulae are treated by fistulotomy. High fistulae require more complex sphincter-preserving techniques. Patients with faecal incontinence should be investigated with anal physiological tests and endoanal ultrasonography. Conservative treatment includes dietary modification, constipating drugs, physiotherapy and biofeedback. Sacral nerve stimulation represents a new, expensive but relatively non-invasive treatment option for patients with faecal incontinence after failure of first-line conservative therapy. Patients with functional constipation should be assessed to distinguish slow transit from obstructed defecation. Laparoscopic ventral rectopexy can be appropriate for selected patients with rectal intussusception.