What conditions does a proctologist (doctor who specializes in the diagnosis and treatment of disorders of the anus and rectum) treat?

What Conditions Does a Proctologist Treat?

A proctologist (also called a colorectal surgeon) specializes in diagnosing and treating disorders of the anus, rectum, and perianal region, managing both emergency and chronic conditions that range from benign inflammatory diseases to life-threatening infections and malignancies. 1

Core Conditions Managed by Proctologists

Emergency Anorectal Conditions

Proctologists handle seven main categories of anorectal emergencies that present with pain or bleeding 1:

• Anorectal abscesses - infections of intersphincteric anal glands that can extend into various anatomical spaces (intersphincteric, ischiorectal, perirectal, supralevator, or horseshoe configurations) 1, 2
• Anal fistulas (fistula-in-ano) - abnormal tracts that arise from preexisting abscesses in approximately one-third of cases, presenting with drainage of blood, pus, or fecal material 1, 2
• Complicated hemorrhoids - including thrombosed, strangulated, or bleeding hemorrhoids requiring urgent intervention 1, 3
• Acute anal fissures - painful tears in the anal canal lining 1, 4
• Retained anorectal foreign bodies - requiring prompt removal 1
• Perineal necrotizing fasciitis - a life-threatening soft tissue infection demanding immediate surgical debridement 1
• Bleeding anorectal varices and complicated anorectal prolapse 1

Chronic Benign Anorectal Disorders

Beyond emergencies, proctologists manage common chronic conditions 5, 6:

• Chronic hemorrhoidal disease - internal and external hemorrhoids causing bleeding, prolapse, or mucus discharge 3, 6
• Chronic anal fissures - requiring medical management with calcium channel blockers, botulinum toxin, or surgical intervention 4
• Complex fistulas - particularly those associated with Crohn's disease, which occur in 13-27% of these patients and may be the initial manifestation in up to 81% 1, 2
• Pruritus ani - perianal itching from various etiologies 5, 6
• Anal discharge and soiling 5, 7

Inflammatory and Infectious Conditions

Proctologists evaluate and treat various forms of proctitis and proctocolitis 1:

• Sexually transmitted proctitis - caused by N. gonorrhoeae, C. trachomatis (including LGV serovars), T. pallidum, and HSV, predominantly in persons who engage in receptive anal intercourse 1
• Proctocolitis - extending beyond the rectum, caused by Campylobacter, Shigella, Entamoeba histolytica, or LGV serovars 1
• Inflammatory bowel disease-related perianal disease - Crohn's disease commonly presents with complex, multifocal fistulas requiring specialized management 1, 2
• Radiation proctitis - following pelvic radiation therapy 1, 8
• Ischemic proctitis 8

Malignancies and Premalignant Lesions

A critical caveat: approximately 11% of anorectal fistulas are caused by malignancy, and carcinomas can rarely arise in chronic fistulas, particularly in Crohn's disease patients 1. Proctologists must evaluate for:

• Anal and rectal cancers - which must be excluded as causes of rectal bleeding 8
• Perianal tumors and precursor lesions 5
• Imaging findings of soft tissue masses, wall thickening, or malignant-appearing lymphadenopathy warrant heightened concern for malignancy 1

Postoperative Complications

Proctologists manage complications following 1:

• Proctectomy, coloproctectomy, or colectomy with pouch anastomosis
• Ileal pouch-anal anastomosis (IPAA) complications including pouchitis
• Rectovaginal and rectovesicular fistulas from obstetric trauma, surgical complications, or radiation injury 1

Key Clinical Presentations

Patients present with only five cardinal symptoms, despite the wide variety of underlying disorders 5:

1. Anal pruritus and burning 5, 7
2. Discharge (mucus, pus, or fecal) 1, 5
3. Bleeding (ranging from minor spotting to life-threatening hemorrhage) 1, 8
4. Pain (from throbbing abscess pain to severe proctalgia) 1
5. Foreign body sensation or swelling 5, 7

Critical Diagnostic Considerations

A major pitfall is that patients frequently conceal anal symptoms due to embarrassment, with studies showing that in five out of six cases, patients do not spontaneously report these symptoms 7. This results in:

• Delayed diagnosis and adverse outcomes 1
• Advanced disease presentation with significant quality of life impairment 1
• Increased healthcare costs from both direct medical treatments and indirect expenses like lost work days 1

Another critical pitfall: incorrect diagnosis is frequent for anorectal diseases, and acute pain can preclude complete clinical examination 1. Therefore, proctologists must:

• Perform thorough anorectal examination including anoscopy when indicated 3, 4
• Utilize appropriate imaging (MRI, endoanal ultrasound, or CT) for complex cases, surgical planning, and when physical examination is limited 1, 2
• Maintain high suspicion for underlying Crohn's disease in patients with recurrent or complex fistulas, assessing for inflammatory bowel disease symptoms 2
• Never assume hemorrhoids without proper examination to exclude other pathology, including malignancy 3, 8