InvestigationsPotential resultsClinical management plan: abnormal results
Symptom assessmentPerianal pruritus mainly present during the night
  1. Consider enterobiosis (eggs are not visible with the naked eye and stool samples are only positive in 5–15%).

  2. Send a sample of transparent adhesive tape (eg, Scotch Tape) applied on the anal area for microscopic analysis.

Due to excess pancreatic enzyme replacementAlter dose.
Visual assessmentChanges due to radiotherapy
  1. If soiling see guidance for faecal incontinence (page 8).

  2. If loose stool/diarrhoea present investigate for possible causes (page 7).

  3. Perianal skin care (pages 19–20).

  4. Topical barrier agent.

  5. Topical corticosteroids (Trimovate (GlaxoSmithKline UK, Uxbridge, UK)).

  6. Consider referral to dermatologist.

No changes due to radiotherapy
  1. Perianal skin care (pages 19–20).

  2. Consider referral to dermatologist.

Protoscopy/flexible sigmoidoscopyHaemorrhoids
  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 GI surgeon regarding treatment with antibiotics and/or drainage.
Anorectal ulcerCheck patient is not on nicorandil.
If radiation 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.

Mucosal prolapse/solitary rectal ulcerRefer to colorectal surgeon/gastroenterologist.
Neoplastic ulcerRefer urgently to appropriate oncology team requesting an appointment within 2 weeks.
  • GI, gastrointestinal; GTN, glyceril trinitrate.