Evaluation and Management of Common Anorectal Conditions American Family Physician escoliosis lumbar leve

The prevalence of benign anorectal conditions in the primary care setting is high, although evidence of effective therapy is often lacking. In addition to recognizing common benign anorectal disorders, physicians must maintain a high index of suspicion for inflammatory and malignant disorders. Patients with red flags such as increased age, family history, persistent anorectal bleeding despite treatment, weight loss, or iron deficiency anemia should undergo colonoscopy. Pruritus ani, or perianal itching, is managed by treating the underlying cause, ensuring proper hygiene, and providing symptomatic relief with oral antihistamines, topical steroids, or topical capsaicin. Effective treatments for anal fissures include onabotulinumtoxina, topical nitroglycerin, and topical calcium channel blockers.Escoliosis lumbar leve symptomatic external hemorrhoids are managed with dietary modifications, topical steroids, and analgesics. Thrombosed hemorrhoids are best treated with hemorrhoidectomy if symptoms are present for less than 72 hours. Grades I through III internal hemorrhoids can be managed with rubber band ligation. For the treatment of grade III internal hemorrhoids, surgical hemorrhoidectomy has higher remission rates but increased pain and complication rates compared with rubber band ligation. Anorectal condylomas, or anogenital warts, are treated based on size and location, with office treatment consisting of topical trichloroacetic acid or podophyllin, cryotherapy, or laser treatment. Simple anorectal fistulas can be treated conservatively with sitz baths and analgesics, whereas complex or nonhealing fistulas may require surgery.Escoliosis lumbar leve fecal impaction may be treated with polyethylene glycol, enemas, or manual disimpaction. Fecal incontinence is generally treated with loperamide and biofeedback. Surgical intervention is reserved for anal sphincter injury.

Anorectal conditions are a common presentation in the primary care setting. A history and physical examination usually will determine the etiology. Physical examination includes visual inspection, digital rectal examination, and anoscopy. Proper use of an anoscope has been described previously in american family physician. 1 for any anorectal condition, malignancy must be considered and excluded as indicated from the history and physical examination. Anal cancer can coexist with benign anal conditions. Red flags (i.E., older age, weight loss, iron deficiency anemia, family history of inflammatory bowel disease or colorectal cancer, and persistent anorectal bleeding despite treatment of a suspected benign condition) warrant evaluation with colonoscopy.Escoliosis lumbar leve the U.S. Preventive services task force recommendations on screening for colorectal cancer are available at http://www.Uspreventiveservicestaskforce.Org/uspstf/uspscolo.Htm. 2 this article reviews the presentation and physical examination findings of benign anorectal disorders and available treatments. A summary of conditions, history and physical examination findings, and treatment options is provided in table 1. 3 – 37

Proctitis presents as rectal discomfort, tenesmus, purulent discharge, abdominal pain, and urgency. The etiology can be infectious (e.G., herpes simplex virus, gonorrhea, chlamydia, human immunodeficiency virus/AIDS), inflammatory, or secondary to radiation or ischemia. A patient with diabetes mellitus or alcoholism who also has perineal pain, sepsis, crepitus, bullae, and induration may have fournier gangrene, a medical emergency requiring immediate antibiotics and debridement. 19

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Condyloma, abscess, polyp, prolapse, hemorrhoid, or anal cancer can present as an anorectal mass. A tender mass that begins insidiously, progressively worsens, and is not exacerbated by defecation may indicate abscess. Patients may report drainage of pus. Acute onset of pain and minimal findings on examination should arouse suspicion for an intersphincteric or deep postanal abscess, which should be addressed immediately by a surgeon before the development of sepsis or a more complicated abscess. A perianal abscess is easily drained with local anesthesia in the office. Antibiotics are often unnecessary after the abscess is drained. 21 immunocompromised patients and patients with diabetes may require hospitalization and intravenous antibiotics.

Rectal prolapse is the complete protrusion of all rectal layers through the anus with straining ( figure 3).Escoliosis lumbar leve because the underlying condition is caused by weakened pelvic support, patients often have concomitant rectocele, cystocele, or other pelvic organ prolapse. Treatment is surgical.

Condylomas (anogenital warts) are easily diagnosed by visual inspection ( figure 4). The extent of involvement should be documented with vaginal speculum examination or anoscopy. Biopsy is needed only if the patient is immunocompromised or if there are atypical features, such as ulceration, pigmentation, fixation, rapid growth, or failure to respond to three rounds of treatment. 22 other sexually transmitted diseases may be present and should be evaluated. Women should have a papanicolaou smear. Multiple treatments are available, but evidence is insufficient to demonstrate superiority of one method over another.Escoliosis lumbar leve all have considerable adverse effects, failure rates, and recurrence rates. 23 condyloma size and location will guide treatment modality: surgical excision, physical or chemical ablation, or immunomodulation. Patients with very large lesions should be referred to a surgeon. Office treatment includes application of topical trichloroacetic acid 80% to 90%, or podophyllin, cryotherapy, or laser treatment. Home treatment includes podophyllotoxin or imiquimod (aldara). Trichloroacetic acid is the only topical treatment approved for use in pregnant women.

Anorectal bleeding can be caused by hemorrhoids, fissures, polyps, diverticular disease, inflammatory bowel disease, or colorectal cancer. 26 , 27 , 41 all anorectal bleeding must be evaluated and diagnosed.Escoliosis lumbar leve colonoscopy is indicated in patients with unexplained bleeding, bleeding that persists despite treatment, associated systemic signs or symptoms (e.G., weight loss, iron deficiency anemia), age older than 40 years, and a family history of colorectal cancer. 41

Hemorrhoids are the most common cause of anorectal bleeding, but can also present as pruritus or a mass on examination. 26 , 27 internal hemorrhoids occur above the dentate line and external hemorrhoids occur below the dentate line. Internal hemorrhoids are classified as grade I to IV based on degree of prolapse ( table 3). Increased fluid and fiber intake should be the initial treatment for symptomatic hemorrhoids. A cochrane review showed fiber supplementation was associated with a 53 percent reduction in the risk of persistent symptoms or bleeding. 28 painful external hemorrhoids can be treated with topical steroids and analgesics.Escoliosis lumbar leve persistent grade I, grade II, and grade III hemorrhoids can be treated by a subspecialist with rubber band ligation, sclerotherapy, or infrared coagulation. Rubber band ligation is the most effective treatment. 29 hemorrhoidectomy decreases the rate of recurrence of grade III hemorrhoids compared with rubber band ligation, but increases the risk of complications and pain, whereas grade IV hemorrhoids are best treated with hemorrhoidectomy. 30 stapled hemorrhoidopexy is a less painful alternative but is associated with a higher rate of recurrence. 31

Fecal impaction is a partial or complete blockage of the colon by hard, dry stool. It presents as constipation or overflow incontinence. Approximately 1 percent of hospitalized older patients and 13 percent of patients with spinal cord injuries experience fecal impaction. 32 etiologies include dietary (low-fiber intake), metabolic (hypothyroidism), drug effects (opiate use), and neurologic (spinal cord injuries).Escoliosis lumbar leve fecal impaction is diagnosed by a history of constipation or overflow incontinence, abdominal and digital rectal examination, and abdominal radiography. Red flags include fever, bloody diarrhea, or elevated white blood cell count, which could signify infection or diverticulitis. Treatment includes oral medications, enemas, suppositories, and manual disimpaction. Oral polyethylene glycol (miralax) plus an electrolyte solution has an 89 percent response rate. 33

Fecal incontinence is the involuntary loss of bowel function, and is a significant source of embarrassment and social isolation. Approximately 2 percent of the general public and 21 percent of community-dwelling older adults experience fecal incontinence. 34 fecal incontinence is clinically classified as overflow (secondary to fecal impaction), reservoir (secondary to diminished colonic or rectal capacity), or rectosphincteric (structural or neurologic damage to the anal sphincter).Escoliosis lumbar leve physicians should ask about symptoms of rectal fullness or urgency. Patients with fecal incontinence may also have urinary incontinence, which should be concomitantly evaluated. A medication history will rule out laxative abuse or other medications associated with diarrhea. Medical and surgical history will identify anal sphincter injury or dysfunction (e.G., previous cerebral vascular accident, intervertebral disk herniation, rectal surgeries, anal sphincter injury during vaginal delivery). Physical examination should include a mini-mental state examination if there is concern for dementia, a thorough neurologic examination, direct anal inspection, and a digital rectal examination to evaluate for impaction or decreased rectal tone. Further diagnostic studies could include anal manometry to evaluate rectal tone, gastrointestinal endoscopy to evaluate for obstructing masses, or ultrasonography and magnetic resonance imaging to evaluate for sphincter defects. 34

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Treatment of fecal incontinence should target the underlying etiology. Begin by removing physical barriers to the bathroom and instituting scheduled defecation schedules for patients with dementia. Fecal impaction should be treated, if present. Biofeedback and antidiarrheal agents such as loperamide (imodium) can be helpful. 34 – 36 patients with incontinence that is refractory to conservative management or with evidence of sphincter injury or dysfunction (e.G., severed sphincter muscles, rectal prolapse, intussusception) should be referred to a surgeon. Surgical treatment options for fecal incontinence include an overlapping sphincter repair, total pelvic floor reconstruction or, less commonly, artificial bowel sphincters. Evidence for the effectiveness of surgical treatment is insufficient; the optimal treatment is likely a combination of nonsurgical and surgical treatments. 37