Not the nicest of topics, but, since it is one I often get asked about, I was glad to see a BMJ article on it. Thoughts:
Most of the causes are things I’d have thought of (thrombosed piles, fungal infection, warts) but it’s worth noting that lichen sclerosus can affect the anal area, and that syphilitic chancres look like fissures and can cause itching rather than pain.
DRE is recommended. In persistently severe cases, proctoscopy/sigmoidoscopy may be recommended to exclude IBD/neoplasms.
Most cases are idiopathic. Management includes:
- Plain water and cotton swabs/soft towels for cleaning after defaecation – avoid both toilet paper (mechanical irritation) and wet wipes (chemical irritation).
- Sitz baths/bidets where available.
- Loose cotton undergarments – these absorb sweat
- Short fingernails to reduce risk of accidentally causing excoriation.
- 1% hydrocortisone for up to two weeks if fungal infection unlikely.
Things to try for faecal leakage include:
- Reduce fibre intake to firm up the stool
- Avoid coffee (even decaff), chocolate, citrus fruits, cola, and calcium/dairy. However, evidence is inconclusive here.
- Cotton wool plug.
Other treatments include topical capsaicin, TCAs, and local methylene blue injections, but all of those are only recommended under specialist supervision.