Anorectal conditions are commonly seen in primary care settings. Bleeding is the most common anorectal presenting symptom in primary care. Screening for colon cancer should be considered for patients with a family history of colorectal cancer and those older than 50 years who are not current on recommended screening. A comprehensive review of the anatomy, diagnostic approach, and treatment of hemorrhoids was previously published in American Family Physician. In most cases, the initial treatment of hemorrhoids is nonsurgical 2 Table 2 3 , 18 , Adequate intake of insoluble fiber 25 to 35 g per day and water reduces bleeding and other symptoms ; the goal should be to pass a daily soft stool without straining.
Food and Drug Administration and calcium dobesilate not available in the United States may help with symptoms of itching, bleeding, or leakage.
Table 3 describes surgical procedures used for treating hemorrhoids and other anal conditions, along with their success and complication rates. One is surgical excision of painful thrombosed external hemorrhoids Figure 1 26 that present within 72 hours of symptom onset.
Surgical excision results in faster symptom resolution than conservative management or simple evacuation of the thrombus 3. The recurrence rate at one year after excisional hemorrhoidectomy is 6. Referral for surgery should also be considered for grade I, II, and smaller grade III hemorrhoids that are not responsive to conservative measures over six weeks.
Rubber band ligation is more effective than injection sclerotherapy or infrared coagulation for these hemorrhoids. Excisional hemorrhoidectomy is the most effective surgical treatment for grade III and IV hemorrhoids, but it has higher rates of postoperative pain and longer recovery time than transanal hemorrhoid artery ligation and stapled hemorrhoidopexy.
