Anorectal conditions for GPs: pruritus ani, haemorrhoids, thrombosed piles and rectal prolapse

Speaker

Colorectal / anorectal surgeon by role (Speakers 1–3 are unnamed in the recording. Speaker 1 describes banding, haemorrhoidectomy, THD, colonoscopy quality metrics, methylene-blue injection and theatre access in the first person — identified by role only).

Audience

GPs ask about oral antifungals before biopsy, wiping versus drying, and thrombosed haemorrhoids (Speaker 2 / Speaker 3 / Unknown Speaker). No names. No sponsor or disclosure statement was captured.

Session context

Otter title Anorectal Conditions Treatment · id YGfR3EF1Dj0VpJqFjB9J7a3oUc4 · ~20 min, recorded 21 March 2026 11:34 am AEST. The recording starts mid-discussion (opening fragment about healing and preferring banding because it is “quick, easy”) and ends with the speaker offering an SMS contact number on a visiting card.

Key messages for GPs

• Painless bright red bleeding is usually haemorrhoids — but tenesmus, change in bowel habit, melaena, a mass on PR, or iron deficiency still means they need a scope (as stated).
• Itchy bottom is mostly managed in GP land. Break the itch–wipe–steroid cycle with barrier cream (e.g. nappy-rash style “pseudo cream” as spoken), fibre, and “try not to touch it”.
• Oral antifungal is worth a trial before biopsy — but only if the patient also keeps the area dry; otherwise it recurs.
• Refractory itch: consider compounded 0.006% capsaicin (not OTC), and as a last step intradermal methylene blue (turns urine green; rare skin necrosis if too much infiltrate).
• Banding is first-line for bothering internal haemorrhoids after a negative scope — but fix the pelvic-pressure / long toilet-sitting habit or they return.
• ~5% interval bowel cancer risk even after a good-quality colonoscopy (Australia/NZ figure as stated) — rethink if an older patient becomes iron deficient again within a few years.
• Most thrombosed external piles: topical high-strength steroid cream, softeners, ice — surgery often hurts longer than the clot; incision under LA only if you are comfortable.
• Irreducible full-thickness prolapse: sugar can desiccate oedema for reduction (as used for stoma prolapse); then surgical repair.

Red-flag bleeding and when to scope

The speaker said GPs “already know” this, but restated the usual red-flag list for anyone with bleeding:

• Painless bleeding — “nearly always going to be haemorrhoids… majority of the time.”
• Still send for a scope if there is tenesmus, change in bowel habit, melaena, a mass on PR, or iron deficiency.
• When a scope is done for bleeding or itch and haemorrhoids are likely, the speaker prefers to treat the haemorrhoids under the same anaesthetic if nothing else is found.

Pruritus ani: cycle, barrier cream, fungus, biopsy

Itchy bottom is “one of the most common things” GPs see; the specialist mainly sees refractory cases. Causes discussed:

• Benign local: regressing haemorrhoids, irritating skin tags, fissures with a sentinel tag.
• Dermatological / systemic: dermatitis, lichen sclerosus (ASR: “sclerosis”), and generalised itch from kidney or liver failure — with one unusual case of biliary obstruction presenting as perianal itch alone that settled when the bile duct was treated.
• The hygiene cycle: patients feel unclean → wipe more → debride and raw skin → steroid cream helps briefly → skin thins → itch returns.

The speaker’s first-line reset (after GPs have usually already tried steroids and thought about punch biopsy):

1. Barrier cream — “pseudo cream” as used for nappy rash; slap it on; try once a day.
2. Fibre to bulk stools.
3. Try not to keep itching or scratching.
4. After a few weeks many improve. Non-responders often have Candida — then biopsy ± flexi/colonoscopy under the same anaesthetic, with fungal cultures. Rare oddities (e.g. Paget’s of the anus) exist but are “rare, weird and wonderful.”

An audience member asked: trial of oral antifungal before biopsy? “Absolutely worth a try” — but patients must also keep the area dry. Tight underwear and hot, sweaty work undo the benefit; symptoms return when the tablets stop.

Seepage from prolapsing haemorrhoids can also cause itch — banding or haemorrhoidectomy may fix that. About 15% never get a clear cause (as stated).

Compounded capsaicin and methylene blue

• Compounded capsaicin cream 0.006% — “very specific”; not over the counter; compounding pharmacy only. Speaker cited about 70% effectiveness (as stated) and said it “resets” the itch sensation.
• Last-line for idiopathic itch: inject methylene blue into the dermis to “kill the nerve endings around the bum”. Lasts a few weeks. Turns urine green — warn patients. Very rarely, too much infiltrate can cause skin necrosis.
• Only after creams, ointments, fibre and bulking are exhausted.

Wiping, drying and steroid duration

• Audience: dry wiping versus hair dryer? Speaker: shower / bathroom (bidet-style, as in “Eastern communities”) is better; pat dry rather than vigorous wipe. Hair dryer “works well” but shower is preferred. (ASR “six bucks” for a device is unclear — not relied on.)
• Lignocaine gel and local-anaesthetic ± steroid haemorrhoid creams can help briefly but are short-acting; patients may overuse them.
• Combination steroid creams: caution using steroid for more than four weeks — skin thinning. “Use it when you need it… stop… use again if it flares.”

Bleeding haemorrhoids: toilet time, banding, THD

If colonoscopy is negative and bleeding is small bright-red spotting, management depends on how much it bothers the patient — many are on anticoagulants. First address the underlying pelvic pressure:

• Two minutes on the toilet, no more — phones / social media prolong sitting, blood pools, haemorrhoids swell and bleed.
• Stool softener (ASR: “Mova coalesce” / Movicol-type — name unverified as spoken).
• Banding if there is a haemorrhoid worth banding. Caveat: if straining continues, bleeding returns in ~six months and banding can be repeated — but without fixing the habit it will keep coming.
• If banding fails and lumps are enlarging: THD (transanal haemorrhoidal dearterialisation — ultrasound-guided stitching) or formal haemorrhoidectomy.
• Copious ongoing bleeding after a good-quality scope usually does not need an immediate repeat scope; if something “isn’t right” (altered habit etc.), reconsider scope ± imaging.

Interval cancer and CT colonography

• Typical interval before thinking about another colonoscopy: about two to three years after a really good-quality exam (as stated), unless symptoms demand earlier review.
• Australia/NZ interval cancer rate ~5% even after full-quality colonoscopy (as stated) — most often right-sided / flexure, where the scope can slip over folds and miss small polyps.
• Older patient suddenly iron deficient again within a couple of years → weigh that 5% against repeat-scope risk. Fit 85–90-year-olds who are independent may still warrant scope when symptomatic.
• CT colonography: reasonable if they cannot tolerate colonoscopy, or for large mass lesions when not a surgical candidate — but misses smaller polyps, is not therapeutic, and only some centres offer it (speaker named South Coast Radiology at John Flynn and Pindara; said some other named providers do not — treat local availability as time-sensitive).
• Colonoscopy quality cited roughly 90–94% for masses (as spoken) — still prefers colonoscopy when possible because polyps can be removed in the same session.

Thrombosed haemorrhoids

Audience: evacuate or leave?

• Incision and clot evacuation under local is possible if the GP is comfortable with a very small nick and the patient accepts it — but the area is “super sensitive” and patients often scream; the speaker with theatre access usually does not do it in rooms.
• Usual counselling: surgery causes more pain for longer than managing with topical treatment. Prefer cream (ASR product names garbled — high-concentration steroid cream, apply about three times a day for two weeks as spoken), no straining, softener. In ~two weeks the clot becomes a skin tag and settles.
• Ice for acute pain — practical tip: freeze water in a glove finger, cut the finger off, apply briefly (~two minutes as spoken).
• Operate now when mucosa is hanging out, extensively clotted and “black” — that needs theatre, not cream temporising.

Prolapse reduction and sugar in ED

• Reduce with patient calm, left lateral, sustained hand or pad pressure until swelling settles.
• Full-thickness prolapse that keeps falling out usually needs surgery — perineal (e.g. Delorme) or abdominal rectopexy. Softeners alone rarely suffice once the sphincter is patulous.
• Cannot reduce: apply sugar (as for stoma prolapse) to draw out water, then reduce; arrange repair (speaker described doing this once in ED then repairing in ~two days).

GP clinic checklist

1. Bleeding + red flags (tenesmus, habit change, melaena, PR mass, iron deficiency) → scope.
2. Itch: stop the wipe cycle; barrier cream + fibre; limit chronic steroid.
3. Consider oral antifungal + keep dry before referring for biopsy.
4. Know that 0.006% compounded capsaicin and (specialist) methylene blue exist for refractory idiopathic itch.
5. Haemorrhoid bleeding: ≤2 minutes on the toilet, softener, then banding discussion.
6. After failed banding with enlarging piles → specialist for THD / haemorrhoidectomy.
7. New iron deficiency within a few years of a “good” scope → remember ~5% interval cancer (as stated).
8. Thrombosed pile: cream / ice / softener first; evacuate under LA only if skilled; phone specialist for severe prolapsing clot.
9. Irreducible prolapse: sugar trick may help reduction; then surgical pathway.

Transcript caveats

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