QS108 - A Pain in the Butt: Incongruency Between Exam Findings and Referral Reasons in Anorectal Visits

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Purpose/Background:

Introduction: Anorectal conditions are prevalent, and often treated in the primary care setting, with only a fraction evaluated by a colorectal surgeon. These conditions can impact quality of life, and can present similarly to more serious conditions such as anal cancer. Meanwhile, anorectal exam education in medical training varies widely and often is limited. We hypothesized that anorectal findings on examination by a colorectal surgeon would frequently not correspond with the referral reason; as such, the aim was to evaluate the most common referring anorectal diagnoses and compare these to exam findings.

Methods/Interventions:

Methods: A retrospective study was performed at a tertiary academic medical center from Jan. 1st, 2023, to Oct. 1st, 2023. Adult patients were identified by screening clinic schedules and were included if the referral reason included anorectal diagnoses such as anorectal bleeding or pain, fecal incontinence, anal lesion including skin tag (without concern for malignancy nor condyloma), hemorrhoid, anal fissure, anal fistula, and perianal abscess. Patients with an existing diagnosis of colorectal or anal cancer, and anal dysplasia were excluded. Patient characteristics, referring provider if any, and exam findings were evaluated.

Results/Outcomes:

Results: Overall, 776 patients met inclusion criteria and were seen by 4 colorectal surgeons over 9 months. Patients had a median age of 45.6 years (interquartile range: 36.6 – 61.2), 50.8% were female, 33.1% were of Non-White race, and 4.0% were Hispanic. Referrals often came from primary care physicians (43.2%) and gastroenterologists (25.0%), with 22.0% being self-referrals and 9.8% being referred by other specialists. The most common referral diagnoses were hemorrhoid in 50.1%, anorectal pain in 29.5%, rectal bleeding in 29.5% and anal lesion in 9.7%, with multiple diagnoses often present. Among 592 patients who had hemorrhoid enlargement on exam, hemorrhoid was a referral reason in 59.1%. Among patients with anal fissure (94) on exam, fissure was a referral reason in only 27.7%. Among patients with anal fistula (69), fistula was a referral reason in 21.7%. Among patients with anal abscess (38), abscess was a referral reason in 50.0%. Among patients with an anal lesion on exam, 3 were concerning for and are now biopsy-proven squamous cell anal cancers with the referral reason for these patients being either bleeding, hemorrhoid, or anal fissure. One patient had a rectal melanoma found on exam and had been referred for bleeding hemorrhoids.

Conclusion/Discussion:

Conclusion: Most patients with anal fissure, anal fistula, and anal lesion on exam were not referred for these diagnoses, and thus, had not received optimal treatment when previously treated. There is enormous opportunity to improve this including early referral to colorectal surgery and increased education on anorectal disorders in training, which can lead to improved diagnosis and treatment, decreased office visits for anorectal complaints due to misdiagnosis, and earlier diagnosis of anorectal cancers.