InvestigationsPotential resultsClinical management plan: abnormal results
Medication assessmentOn nicorandilLiaise with cardiology team and GP to offer alternative medication.
Visual assessment

1st Line
Anoscopy and flexible sigmoidoscopy

2nd Line
  1. Stool bulking/softening agent ± short-term topical local anaesthetic.

  2. Consider referral for surgical review for grade 3 or 4 haemorrhoids.

Anal fissure
  1. Topical healing agent, eg, GTN or diltiazem gel (for 8 weeks).

  2. Stool bulking/softening agent ± short-term topical local anaesthetic.

  3. If fissure not healed after 2 months, refer for surgical opinion.

Anorectal fistula
  1. Pelvic MRI.

  2. Refer to a colorectal surgeon.

Anorectal abscessThis is an emergency
Discuss immediately with a colorectal surgeon regarding treatment with antibiotics and/or drainage.
Anorectal ulcerCheck patient is not on nicorandil.
Mucosal prolapse/solitary rectal ulcerRefer to GI surgeon/gastroenterologist.
Neoplastic ulcerRefer urgently to appropriate oncology team requesting an appointment within 2 weeks.
If radiation-ulceration relatedDo not biopsy
  1. Sucralfate enemas.

  2. Consider stool bulking/softening agent.

  3. Antibiotics.

  4. Consider hyperbaric oxygen therapy.

  5. Refer to a specialist centre.

If all tests are negative, but symptoms persist
  1. Consider investigation under anaesthesia.

  2. Pelvic floor and toileting exercises (page 18).

  3. Stool bulking agent ± laxative.

  4. Consider a referral for acupuncture.

  5. Consider referral to a specialist pain team.

  6. Consider a low-dose antidepressant.

  7. Consider an agent for neuropathic pain.

  8. Consider referral for a urological/gynaecological opinion.

  • GI, gastrointestinal; GP, general practitioner; GTN, glyceril trinitrate.