Internal Medicine

0521779407-B01 CUNY1086/Karliner 0 521 77940 7 June 4, 2007 20:52

Benign Disorders of the Rectum and Anus 227

management

What to Do First

■Establish diagnosis

General Measures

■Pain relief w/ sitz baths & local therapy

specific therapy

■Hemorrhoids:

➣Most pts require no treatment except counseling for high-fiber

diet

➣Grade 2 & 3 hemorrhoids often may be treated w/ hemorrhoid

banding; sclerotherapy less commonly used

➣Surgery may be used for grade 2–4 hemorrhoids but not neces-

sary unless pt dissatisfied w condition

➣Thrombosed hemorrhoids may be treated expectantly if small,

or may require opening & evacuation of clot or urgent hemor-

rhoidectomy

■Fissure:

➣Initial trial of fiber & stool softeners; trial nitroglycerine ointment

to anus TID if persists

➣Surgical options include botulinum toxin injection or division of

internal sphincter or rectal dilatation under anesthesia

■Condyloma:

➣Topical podophylin, laser therapy, coagulation, or surgical exci-

sion (rare)

■Rectal prolapse:

➣Transabdominal rectopexy; sigmoid resection & rectopexy; Alt-

meier procedure (transanal resection of prolapse)+/−levatoro-

plasty

■Incontinence:

➣Mild incontinence may be manageable w/ diet & bulk agents to

produce firmer stools

➣If caused by sphincter injury, pt may benefit from sphincter

reconstruction Limited experience to date w/ artificial sphinc-

ters; arely, colostomy may be appropriate

follow-up

■Hemorrhoids, prolapse, & incontinence do not require follow-up

except for symptomatic recurrence

■Typical fissures that resolve w/ management do not require follow-

up