Anorectal symptoms and complaints are common and may be caused by a wide spectrum of conditions. Although most conditions are benign and may be successfully treated by primary care practitioners, a high index of suspicion for colorectal cancer should be maintained, and all patients should be appropriately investigated. Inspection, palpation and anoscopic examination using an Ive's slotted anoscope provide adequate initial assessment. Pruritus ani usually represents a self-perpetuating itch-scratch cycle and is uncommonly due to infection. The history, as well as the physical examination, can distinguish anal pain due to hemorrhoids, fissure, abscess, cancer or proctalgia fugax. The most frequent causes of rectal bleeding are hemorrhoids, fissures and polyps. Diagnoses associated with difficulty in passing stool can range from constipation to fecal incontinence.
Patients frequently consult primary care physicians because of concerns about or symptoms related to the anorectal area. Although many anorectal conditions are benign and easily treated, patients may delay seeking medical advice because of embarrassment or fear of cancer. Thus, both malignant and nonmalignant conditions often present as advanced disease, requiring more extensive treatment and causing greater patient distress than if conditions had been adequately diagnosed and managed at an earlier stage.
Conversely, both patients and physicians should be aware of the need for adequate assessment of all anorectal symptoms because of the high incidence of colorectal cancer. The average American is estimated to have a one in 18 lifetime risk of developing colorectal cancer.1 This risk is equal for men and women and increases with age. In 2001, an estimated 138,000 new cases of cancer of the colon, rectum or anus will be diagnosed; these cancers will cause the death of more than 57,200 adults each year in the United States.1 In nonsmokers, colorectal cancer is the leading cause of death from cancer.
Colorectal cancer may present as rectal bleeding and coexist with a benign condition such as hemorrhoids. Every patient with anorectal symptoms, especially those with rectal bleeding, must have an assessment that includes, at a minimum, digital rectal examination and visual inspection by anoscope. Increasing access to primary care physicians leads to earlier detection of colorectal cancer.
Current American Academy of Family Physicians (AAFP) and American Cancer Society (ACS) guidelines call for screening of all patients for colorectal cancer beginning at 50 years of age in the general population and 40 years of age in those with risk factors or a family history of the disease.3 Family physicians can play a major role in the prompt recognition of cancer and appropriate management of other anorectal conditions. All clinicians can and must perform a basic examination to appropriately treat or refer patients with anorectal complaints. After proper evaluation, the majority of nonmalignant anorectal conditions can be treated by the primary caregiver.