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In this webinar and Q&A session, experienced surgeon A/Prof Maurice Brygel outlines how to manage common anal-rectal conditions in the primary care setting. He provides valuable insights on addressing the anal-rectal conditions you may come across as a GP.

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Q&A with A/Prof Maurice Brygel

Q: How do you differentiate between benign anal fissure and mild Crohn’s disease or early anal cancer?
A: Acute and chronic anal fissures are usually in the midline, most commonly posterior. With Crohn’s disease the fissure may be in any position and is much more irregular and ragged. It may not be painful. There are usually symptoms of Crohn’s disease as well. With anal carcinoma there may be an ulcer or a lump which is usually tender. We also see carcinoma in situ. This is usually just observed as it is viral in origin. Calcium channel blockers nifedipine may be used for anal fissure as a local application, as well as rectogesic cream and Botulinum toxin injections.

Q: What is the best treatment for first, second, third, and fourth degree haemorrhoids?
A: Treatment of stage 1 haemorrhoids stage involves a healthy diet, keeping the bowels regular and avoiding straining. These measures are similar for stage 2 but may also include sclerotherapy or preferably rubber band ligation. For stage 3, there is a choice of these treatments or surgical excision depending on the patient’s preferences, health and the severity of their condition. With stage 4, surgery is usually required.

Q: What is your post-operative advice after treatment? Analgesia, sitz bath, rectogesic or diltiazem ointment?
A: Post-operative analgesia is required. Sitz baths and local applications are also very useful. Even flagyl orally has been shown to be effective. Patients should take prunes to keep the bowels soft.

Q: With regards to anal skin tag removal, how much skin can you remove before you risk anal stenosis?
A: With skin tags there should be no risk of anal stenosis as skin tags are superficial. With skin tag excision one does not enter the anal canal and should not excise deeper.

Q: Can you use rubber banding to treat small rectal prolapses?
A: It is not always possible to distinguish between haemorrhoids and a small rectal prolapse. Prolapse does not have the blue venous colour. However, one could use rubber band ligation where it is mucosal only and see how it goes. However, one cannot put banding onto the skin below the dentate line because of the pain involved.

Q: A young 20-year-old patient presented with two to three episodes of passing red blood after passing stools. There was a family history of bowel cancer in a 60-year-old family member. Upon examination, there was no other history, no pain when defecating, no constipation, and no change in bowel motion. What would be the recommended investigations and management?
A: The family history aspect would depend whether it is a parent. These patients need to be referred to a specialist because it is found that bowel cancer is presenting in young people as well. Generally, for the first presentation even in young men with bleeding, proctoscopy and sigmoidoscopy are at least required, and maybe a colonoscopy. The extent of family history determines the age and frequency of the screening program.

Additionally, anal fissures in children are usually due to constipation. This can be treated with adequate toilet training, a healthy diet rich in vegetables, lactulose, Coloxyl drops, and/or paraffin oil or local anaesthetic.

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