An Evidence-Based Practical Review on Common Benign Anorectal Disorders: Hemorrhoids, Anal Fissure, Dyssynergic Defecation, and Fecal Incontinence.

Abstract

This evidence-based practical review is focused on the clinical features, investigations, and treatment of hemorrhoids, chronic anal fissures, dyssynergic defecation (DD), and fecal incontinence (FI), which are arguably the most common benign anorectal diseases encountered by gastroenterologists. These diseases are associated with bowel disturbances, which should be evaluated preferably with questionnaires, and with anal weakness and/or DD, often evident on a thorough digital rectal examination. Fissures and DD are closely linked to constipation, whereas FI is typically associated with diarrhea. For most patients with mild symptoms, lifestyle changes, dietary adjustments, and/or pharmacotherapy suffice. Some patients require tests to rule out serious diseases; assess anorectal functions, which are discussed in detail; and to identify structural abnormalities, such as rectoceles, which are occasionally clinically significant. Treatments are applied stepwise, starting with conservative therapy with simpler treatments when feasible (eg, rubber band ligation for grade I-II hemorrhoids), with surgery, usually excisional hemorrhoidectomy, being reserved for more severe disease; for anal fissures, topical therapy using a calcium channel antagonist or nitroglycerine, followed by botulinum toxin and, less frequently, lateral internal sphincterotomy for chronic fissures. Anorectal biofeedback therapy is effective for managing DD and, together with bowel modifiers tailored to the specific symptoms (ie, constipation and/or diarrhea), is also used for FI. Biofeedback therapy is not widely accessible, and many patients are treated by pelvic floor physical therapists. For FI, minimally invasive options include sacral neuromodulation and anal dextranomer injection, with colostomy or anal sphincteroplasty now rarely required. Surgical interventions must balance long-term effectiveness with potential risks. Key topics for future research are proposed.