Common Anal Conditions · Version 2.0

Final Quick-Reference Section

Dr. Tamer Rushdy Elalfy · 5 min read

In this chapter

The 20 Most Dangerous Anorectal Mistakes
The 20 Red Flags That Require Same-Day Escalation
The 10 Rules for Safe Anorectal Examination
The 10 Essential Referral Triggers

The 20 Most Dangerous Anorectal Mistakes

No.	Item
1	Calling anorectal bleeding “piles” without inspection, DRE, and anoscopy.
2	Treating bleeding haemorrhoids in a patient with iron-deficiency anaemia or other alarm features before the colon is examined.
3	Discharging a febrile patient with perianal pain on antibiotics alone.
4	Waiting for fluctuance before draining an abscess.
5	Missing an intersphincteric abscess because the skin looked normal.
6	Delaying Fournier’s surgery for CT, MRI, or a score.
7	Missing the SGLT2-inhibitor link and euglycaemic ketoacidosis.
8	Discharging the post-banding pelvic sepsis triad as “discomfort”.
9	Banding irreducible, thrombosed, or external tissue — or rectal varices.
10	Prescribing GTN to a patient using a PDE5 inhibitor or riociguat.
11	Sphincterotomy or fistulotomy in an atypical fissure, complex fistula, or active Crohn’s disease.
12	Repeating steroid creams for a non-healing lesion and missing anal cancer.
13	Excising, banding, or cauterising a suspicious lesion without histology.
14	Giving loperamide for overflow from faecal impaction.
15	Routine rectal instrumentation in profound neutropenia — or letting that rule delay surgical review.
16	Reducing gangrenous prolapsed bowel.
17	Pulling a foreign body against a contracted sphincter, breaking glass, or grasping drug packets.
18	Missing STI proctitis (including LGV) or HIV because no sexual history was taken.
19	Delaying HIV PEP or emergency contraception after sexual assault.
20	Missing cauda equina syndrome, intussusception, or a safeguarding concern presenting as an “anal” problem.

The 20 Red Flags That Require Same-Day Escalation

No.	Item
1	Perianal pain with a temperature above 38.0 °C.
2	Severe rectal pain with fever and normal-looking skin.
3	Perineal pain out of proportion, crepitus, dusky skin, or bullae.
4	Perineal infection in a patient with diabetes, immunosuppression, or an SGLT2 inhibitor.
5	Worsening pain, fever, or urinary difficulty after banding or anorectal surgery.
6	Bleeding soaking more than 1 pad per hour, or clots, after a procedure.
7	Shock index > 1, syncope, or haemodynamic instability with rectal bleeding.
8	Inability to pass urine for 6–8 hours after a procedure.
9	Prolapsed rectum or haemorrhoids that are dusky, black, or irreducible.
10	Rectal foreign body with peritonism, free air, a sharp object, or drug packets.
11	Abdominal pain, distension, or fever in a patient with faecal impaction.
12	Perianal pain or fever in a neutropenic patient.
13	New faecal incontinence with back pain, saddle numbness, or urinary retention.
14	Sexual assault within 72 hours (HIV PEP) or 120 hours (emergency contraception).
15	A child with redcurrant-jelly stool, colicky pain, and lethargy.
16	A child with bloody diarrhoea and pallor or reduced urine output.
17	Any safeguarding concern in a child or vulnerable adult.
18	Perianal abscess in pregnancy.
19	Perianal sepsis in known Crohn’s disease or in a patient on biologics.
20	Severe constipation with abdominal pain in a patient taking clozapine.

The 10 Rules for Safe Anorectal Examination

No.	Item
1	Check Appendix C before touching the rectum.
2	Explain, obtain consent, and offer a chaperone.
3	Position well: left lateral at the edge of the couch, with good light.
4	Look before you feel — inspect at rest and on straining.
5	Give lidocaine gel 5–10 minutes to work.
6	Never force — stop and book EUA if pain prevents a safe examination.
7	Record resting tone, squeeze, and push separately.
8	Use anoscopy to see internal haemorrhoids.
9	Examine both groins when you find a lesion.
10	Document by anatomical quadrant and distance from the verge — never by clock face alone.

The 10 Essential Referral Triggers

No.	Item
1	Any same-day red flag above → emergency or same-day surgical review.
2	Alarm features or a positive FIT → colon evaluation (Chapter 08).
3	Anal mass, non-healing ulcer or plaque, or inguinal nodes → suspected-cancer pathway (Chapter 07).
4	Atypical fissure, recurrent abscess, or complex fistula → colorectal surgery ± gastroenterology (Chapter 09).
5	Chronic fissure not healed after 6–8 weeks of medical therapy → surgical clinic.
6	Haemorrhoids failing 4–6 weeks of conservative care → office-procedure clinic.
7	STI proctitis or anorectal ulcer → sexual-health service (Chapter 11).
8	Faecal incontinence after stepped care, or after OASIS → pelvic-floor or colorectal service (Chapters 10, 13).
9	Recurrent rectal prolapse in a child → paediatrics and sweat test (Chapter 14).
10	Persistent symptoms when examination is impossible → examination under anaesthesia.