Anorectal Consultation
Created by
Jason Wilson
Specialty
Colorectal Surgeon
Last edited
10/20/2026
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About this template
A structured template for documenting anorectal consultations, including referral details, presenting symptoms, relevant history, examination findings, investigations, and the assessment and plan. It supports comprehensive clinical documentation while including only information explicitly stated in the information provided.
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I appreciate the referral of David Miller regarding painless bright red rectal bleeding and prolapsing tissue. He is 46 years old and male. The consultation took place in the office on 14/05/2024.
Painless bright red blood per rectum (BRBPR) with bowel movements for the past 6 months, progressive over the last 4 weeks, associated with intermittent prolapsing tissue requiring manual reduction.
FIT negative (10/03/2024). Hb 142 g/L (12/04/2024).
Current Symptoms
Bleeding: Bright red blood on toilet paper and dripping into the bowl post-defecation. No melena or clots.
Pain: None. Mild perianal discomfort only when tissue prolapses.
Bowel habits: Chronic constipation; hard stools q2-3d with significant straining. No recent change in caliber.
Continence: Fully continent to flatus, liquid, and solid stool.
Discharge: Occasional mild mucus staining on undergarments.
Hemorrhoids: Prolapsing tissue noted after defecation, requiring manual reduction.
Past Medical History: HTN, GERD.
Past Surgical History: Laparoscopic appendectomy (2012).
Medications: amlodipine (Norvasc®) 5 mg PO daily, pantoprazole (Pantoloc®) 40 mg PO daily.
Allergies: NKDA.
Social History: Non-smoker, ETOH 2-3 drinks/week. Works as a long-haul truck driver.
Family History: Negative for CRC, IBD, or polyps.
Investigations: Colonoscopy (2021) - normal to cecum, internal hemorrhoids noted.
Examination
Anorectal
Hemorrhoids: Prominent Grade III internal hemorrhoids at left lateral, right anterior, and right posterior positions on anoscopy. No thrombosis.
Fissure: None.
Abscess: None.
External opening: None.
Tender: Non-tender to palpation.
DRE
Tone: Normal resting tone.
Squeeze: Strong, symmetric.
Mass: No palpable masses. Prostate smooth, non-enlarged.
Tender: Non-tender.
Assessment and Plan
46yo M presenting with symptomatic Grade III internal hemorrhoids secondary to chronic constipation and straining.
Performed rubber band ligation (RBL) of the largest right anterior internal hemorrhoid column today in clinic. Advised high-fiber diet (25-30 g/day), increased fluid intake, and prescribed polyethylene glycol 3350 (RestoraLAX®) 17 g PO daily to soften stools and prevent straining. Sitz baths TID PRN for post-procedure comfort.
Flexible sigmoidoscopy is not indicated given normal complete colonoscopy 3 years ago and classic outlet-type bleeding.
Discussed benefits and risks of RBL, including pain, bleeding, vasovagal response, and rare pelvic sepsis. Informed consent was obtained prior to the procedure.
Follow-up in 6 weeks for reassessment and potential repeat banding of remaining columns. If conservative measures and RBL fail to control symptoms, will discuss excisional hemorrhoidectomy.
Thank you for allowing me to participate in this patient's care.
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