›Immediate priorities
›Monitoring
›Continuous pulse oximetry if systemic illness
›Cardiac monitor if hypotension or tachycardia
›IV access
›Two large bore IV if bleeding concern
›One IV if analgesia and fluids needed
›Fluids
›Crystalloid bolus 500 mL to 1000 mL if hypotension
›Reassess after each bolus
›Analgesia early
›Acetaminophen PO 1000 mg once
›Ketorolac IV 15 mg once
›Avoid NSAID if bleeding risk
›Morphine IV 2 mg
›Reassess every 10 minutes
›Sepsis pathway if indicated
›Broad spectrum antibiotics within 60 minutes local protocol dependent
›Lactate
Therapeutic management by diagnosis
›Anal fissure management
›Stool softening
›Polyethylene glycol 17 g PO daily
›Titrate to soft stool
›Topical analgesia
›Lidocaine 2 to 5 percent topical small amount up to 3 times daily
›Avoid excessive dosing
›Sphincter relaxation topical
›Nitroglycerin 0.2 to 0.4 percent ointment small amount twice daily
›Headache risk
›Hypotension risk
›Avoid with PDE5 inhibitors recent use
›Diltiazem 2 percent topical small amount twice daily
›Local compounding often required
›Warm sitz baths
›10 to 15 minutes
›2 to 3 times daily
›Thrombosed external hemorrhoid management
›Symptom duration decision
›Less than 72 hours
›Consider excision under local anesthesia if severe pain
›Local protocol dependent
›Greater than 72 hours
›Conservative management preferred
›Conservative regimen
›Acetaminophen scheduled
›NSAID if safe
›Topical lidocaine
›Stool softener
›Hemorrhoids internal management
›Constipation management
›Fiber supplement
›Polyethylene glycol 17 g PO daily
›Topical steroid short course
›Hydrocortisone topical limited 7 days
›Avoid prolonged use
›Ongoing bleeding referral
›Outpatient GI or colorectal surgery
›Colonoscopy consideration age based
›Perianal abscess management
›Drainage
›I and D for superficial fluctuant abscess
›Analgesia and local anesthesia
›Antibiotics indications
›Systemic toxicity
›Extensive cellulitis
›Immunocompromised
›Diabetes mellitus (E11.9)
›Valvular heart disease high risk local protocol dependent
›Antibiotic options
›Amoxicillin clavulanate PO 875 mg twice daily
›TMP SMX PO 1 DS tablet twice daily
›Add metronidazole PO 500 mg twice daily
›Penicillin allergy alternatives local protocol dependent
›Deep abscess concern
›CT abdomen pelvis
›Colorectal surgery consult
›Fournier gangrene management
›Immediate actions
›Emergent surgical consult
›Broad spectrum IV antibiotics
›Piperacillin tazobactam IV 4.5 g every 6 hours
›Add vancomycin IV dosing by weight and renal function local protocol dependent
›Add clindamycin IV 900 mg every 8 hours toxin suppression
›Do not delay OR for imaging if high suspicion
›Infectious proctitis management
›Supportive and testing first
›Rectal NAAT for gonorrhea
›Rectal NAAT for chlamydia
›Empiric therapy criteria
›Severe symptoms with high STI risk
›Awaiting results with unreliable follow up
›Local protocol dependent
›Example empiric regimen
›Ceftriaxone IM 500 mg once
›Doxycycline PO 100 mg twice daily 7 days
›If lymphogranuloma venereum concern
›Extend doxycycline to 21 days local protocol dependent
›Herpes proctitis regimen
›Acyclovir PO 400 mg three times daily 7 to 10 days
›Valacyclovir PO 1000 mg twice daily 7 to 10 days