Benign Anorectal Disorders Clinical Practice Guidelines (ACG, 2021)

American College of Gastroenterology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

October 29, 2021

Guidelines on the management of benign anorectal disorders were published in October 2021 by the American College of Gastroenterology (ACG) in The American Journal of Gastroenterology.[1] Selected recommendations and concepts are summarized below.

Defecation Disorders (DDs)

Symptoms that suggest DD include excessive straining during defecation, sense of anorectal blockage during defecation, use of manual maneuvers to aid evacuation, and a sense of incomplete evacuation after defecation.

Digital rectal examination (DRE) is strongly recommended in the evaluation to identify structural anomalies (ie, anal fissures, hemorrhoids, fecal impaction, descending perineum syndrome, or anorectal cancer) and assess anal sphincter function.

A DD diagnosis requires anorectal manometry (ARM) and balloon expulsion.

Instrumental anorectal biofeedback therapy is strongly recommended for management of DDs.

In the setting of failed conservative therapy and biofeedback, defecography (magnetic resonance [MR] or barium) may be necessary.

Surgical therapy is not necessary in most cases of structural anomalies owing to the high prevalence of asymptomatic patients with such findings, and low-level evidence for and moderate risks of surgery.

It is suggested that full-thickness rectal prolapse often necessitates surgical intervention with abdominal rectopexy or, in selected cases, a perineal procedure.

Proctalgia Syndromes

Characteristic features of chronic proctalgia syndrome are a history of recurring anorectal pain episodes of at least 20-minutes’ duration and the exclusion of other pain causes by history and diagnostic testing. Tenderness on palpation of the levator ani muscles reinforces the diagnosis. It is the duration rather than the frequency of proctalgia episodes that aids the diagnosis of chronic proctalgia in the general population.

The presence of levator tenderness and the absence of other potential etiologies is sufficient to diagnose levator syndrome in patients with chronic proctalgia. Idiopathic chronic proctalgia syndrome is defined by the absence of levator tenderness in those with chronic proctalgia.

Clinical history and a normal DRE alone are sufficient to diagnose proctalgia fugax.

ACG strongly recommends biofeedback to teach pelvic floor muscle reconditioning for levator syndrome with abnormal ARM. If biofeedback is unavailable, ACG suggests a trial with electrical (galvanic) stimulation for management of levator syndrome with abnormal ARM.

No evidence supports the use of Botox or digital massage in chronic proctalgia syndromes.

Anal Fissures

Chronic anal fissures are those that last longer than 8-12 weeks and feature edema and fibrosis. They persist as nonhealing ulcers by anal sphincter spasm and result in ischemia. In general, management consists of stool softening and spasm reduction for improved regional perfusion.

ACG strongly recommends initial medical treatment of chronic anal fissure be local application of a calcium channel blocker (CCB).

ACG suggests a trial of botulinum toxin A injections in the setting of failed CCB therapy or as an alternative option to CCB. Another treatment option for chronic anal fissures is nitroglycerine.

Lateral internal sphincterotomy is strongly recommended as the surgical treatment of choice for chronic anal fissures refractory to nonsurgical measures.


Cardinal signs of internal hemorrhoids are painless bleeding and intermittent protrusion. The diagnosis generally requires exclusion of other conditions with similar symptoms.

Thrombosis of external hemorrhoids may result from clot formation in a vein under the squamous epithelium of the anal verge.

ACG strongly recommends first-line therapy for symptomatic hemorrhoids include dietary modification with adequate fluid and fiber intake, as well as counseling to minimize straining at defecation.

It is strongly recommended patients with acute thrombosed external hemorrhoids that are seen within the first 4 days may benefit from either surgical excision or incision and evacuation of the thrombus.

ACG strongly recommends symptomatic grade 1 and 2 internal hemorrhoids refractory to medical therapy can be successfully treated with office-based procedures (eg, rubber band ligation). Other procedures include infrared coagulation, sclerotherapy, and bipolar coagulation.

For symptomatic grade 3 hemorrhoids, it is suggested that Doppler-guided procedures (eg, hemorrhoidal artery ligations) have similar outcomes to hemorrhoidectomy.

Fecal Incontinence (FI)

FI is defined as the involuntary loss of solid or liquid feces, including underwear staining.

No single test is a gold standard for the diagnosis of FI. Functional tests (ARM, balloon evacuation testing, sensory evaluation) and imaging studies (endoanal ultrasonography, MR imaging) are complementary.

Conservative measures (ie, education, preventative diarrheal measures, pelvic floor exercises) are safe, inexpensive, and usually effective.

There is insufficient evidence about the benefits of laxatives in pediatric and older patients who have FI and constipation. Insufficient safety and efficacy data exist for some invasive procedures (eg, SphinKeeper).

Strong recommendations

  • Setting of FI with diarrhea: Antidiarrheal agents (eg, loperamide, diphenoxylate with atropine, bile salt binding agents, anticholinergic agents, clonidine)

  • Nonresponse of patients with FI to education and conservative measures: Biofeedback (ie, pelvic floor rehabilitative techniques with visual/auditory feedback)

  • Moderate to severe FI refractory to conservative measures, biofeedback, and other low-cost, low-risk techniques: Sacral nerve stimulation (SNS)

Conditional recommendations

  • Selected patients with nonresponse to conservative measures and biofeedback: Consider anal plugs, vaginal balloons, and other devices to impede defecation.

  • Selected patients with FI with nonresponse to conservative therapy or biofeedback: Injection of bulking agents (eg, dextranomer sodium) is suggested.

  • Acute injuries to the anal sphincters: Anal sphincteroplasty is suggested.

  • Severe FI refractory to other therapies: ACG suggests offering an end stoma to affected patients.

For more information, please go to Anal Fissure, Anal Fistulas and Fissures, Hemorrhoids, and Fecal Incontinence.


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