Thoracic Back Pain

Last updated 31 May 2026 · Musculoskeletal

📋 Key Information Summary

📋

Thoracic back pain (T1–T12) affects 15–19% of Australian adults and is less common than lumbar pain but carries higher risk of serious underlying pathology.
A structured diagnostic model using history, physical examination, and red-flag screening is essential before attributing pain to a musculoskeletal source.
Non-musculoskeletal causes — including acute coronary syndrome (ACS), aortic dissection, oesophageal rupture, and biliary disease — must be excluded through targeted questioning and investigation.
Red flags requiring urgent investigation include: age of onset >50 years, history of malignancy, unexplained weight loss, fever, intravenous drug use, thoracic fracture, progressive neurological deficit, and night pain unrelieved by rest.
Costovertebral joint dysfunction is an under-recognised cause of thoracic back pain presenting with localised paravertebral pain worsened by deep inspiration, coughing, or rotation.
Diagnosis of costovertebral joint dysfunction is clinical; provocative manoeuvres (Costovertebral Compression Test) and palpation of the affected joint reproduce symptoms.
Aortic dissection classically presents with sudden-onset tearing interscapular pain radiating to the back; systolic blood pressure difference >20 mmHg between arms is a critical clue. Urgent CT aortogram is required.
Cardiac causes (ACS, pericarditis) may present as thoracic back pain — a 12-lead ECG and troponin should be performed in patients with cardiovascular risk factors.
Oesophageal causes include gastro-oesophageal reflux disease (GORD), Boerhaave syndrome (spontaneous rupture), and oesophageal spasm; odynophagia and pleuritic retrosternal pain are key features.
Biliary colic and acute cholecystitis may refer pain to the right infrascapular region; RUQ ultrasound and LFTs are first-line investigations.
First-line management for musculoskeletal thoracic back pain includes patient education, activity modification, paracetamol, and short-course NSAIDs; muscle relaxants are second-line only.
Aboriginal and Torres Strait Islander Australians experience higher rates of musculoskeletal pain, delayed presentation, and barriers to specialist access — culturally safe care and outreach models are critical.

Introduction & Australian Epidemiology

Thoracic back pain encompasses pain arising from structures in the region between the superior border of T1 and the inferior border of T12, including the thoracic vertebral column, costovertebral and costotransverse joints, intervertebral discs, paravertebral musculature, ribs, and overlying soft tissues. Compared with cervical and lumbar spine pain, thoracic back pain has historically received less research attention, yet it affects a substantial proportion of the Australian population and is a frequent presentation in general practice.

Australian population data suggest that the point prevalence of thoracic back pain in adults ranges from 15% to 19%, with women affected more commonly than men. The condition is most prevalent in the 20–55-year age group, with a second peak in older adults due to osteoporotic vertebral compression fractures. In Australian primary care, thoracic back pain accounts for approximately 3–5% of all musculoskeletal consultations.

The thoracic spine is inherently more stable than the cervical and lumbar segments due to the articulation with the rib cage, the coronal orientation of the facet joints, and the narrower intervertebral disc height. These anatomical features limit flexion, extension, and rotation but make the region susceptible to dysfunction at the costovertebral and costotransverse joints. Additionally, the proximity of vital thoracic and abdominal viscera means that non-musculoskeletal causes — including cardiac, vascular, oesophageal, and hepatobiliary pathology — frequently present as thoracic back pain and must be systematically excluded.

⚠️

Clinical pearl: Thoracic back pain is more likely than lumbar back pain to have a serious underlying cause (malignancy, infection, fracture, visceral referred pain). Always apply a structured red-flag screen before concluding a benign musculoskeletal aetiology.

Thoracic Back Pain Diagnostic Model

A systematic diagnostic approach to thoracic back pain uses a biopsychosocial framework with emphasis on pattern recognition, red-flag exclusion, and clinical reasoning. The following stepwise model guides Australian clinicians from initial assessment through to diagnosis.

Red-Flag Screening

Exclude serious pathology (malignancy, infection, fracture, aortic dissection, ACS) through targeted history and examination. If red flags are present, proceed to urgent investigation before considering musculoskeletal diagnosis.

Visceral Referred Pain Exclusion

Assess for non-musculoskeletal causes including cardiac, aortic, oesophageal, and gall bladder pathology. Key features include pain unrelated to movement, associated autonomic symptoms, and systemic features.

Mechanical / Musculoskeletal Pattern Recognition

Characterise pain: is it related to movement, posture, or loading? Localised paravertebral pain reproduced by palpation, rotation, or deep inspiration suggests costovertebral dysfunction. Diffuse aching after sustained postures suggests myofascial pain.

Neurological Assessment

Evaluate for thoracic radiculopathy (dermatomal band-like pain, altered sensation) or myelopathy (gait disturbance, upper motor neuron signs, bowel/bladder dysfunction). Myelopathy is a surgical emergency.

Psychosocial & Yellow-Flag Assessment

Screen for psychosocial contributors: fear-avoidance, catastrophising, workplace stress, comorbid depression/anxiety. Use the STarT Back Screening Tool or Örebro Musculoskeletal Pain Questionnaire where appropriate.

Diagnostic Categories

Category	Examples	Key Diagnostic Features
Mechanical / MSK	Costovertebral dysfunction, facet joint syndrome, thoracic disc prolapse, myofascial pain, Scheuermann disease	Pain reproducible with movement or palpation; no systemic features
Visceral referred	ACS, aortic dissection, GORD, cholecystitis, pancreatitis, peptic ulcer	Pain unrelated to movement; associated autonomic or GI symptoms
Neoplastic	Metastatic vertebral disease (breast, lung, prostate, renal, thyroid), multiple myeloma, primary bone tumour	Progressive pain, night pain, weight loss, history of malignancy
Infectious	Vertebral osteomyelitis, discitis, epidural abscess, tuberculosis (Pott disease)	Fever, elevated CRP/ESR, IV drug use, immunosuppression
Inflammatory	Ankylosing spondylitis, psoriatic arthritis, enteropathic arthritis	Morning stiffness >30 min, improvement with exercise, HLA-B27 association
Osteoporotic fracture	Compression fracture (T7–T12 most common)	Acute onset after minor trauma or spontaneous; age >65, corticosteroid use

Non-Musculoskeletal Causes

Thoracic back pain may be the presenting complaint of several life-threatening visceral conditions. Clinicians must maintain a high index of suspicion and systematically exclude these diagnoses before attributing pain to a musculoskeletal source.

Cardiac Causes

Acute coronary syndrome (ACS) — particularly posterior myocardial infarction — may present as interscapular or thoracic back pain rather than classical central chest pain. This atypical presentation is more common in women, older adults, and patients with diabetes mellitus. Acute pericarditis may also cause thoracic back pain, characteristically pleuritic and relieved by sitting forward.

🚨

Time-critical: Any patient presenting with acute thoracic back pain and cardiovascular risk factors must have a 12-lead ECG performed within 10 minutes. Do not attribute to musculoskeletal cause until ACS is excluded. For posterior MI, obtain posterior leads (V7–V9).

💊

Aspirin

Aspro-Protect® · Cartia® · Antiplatelet

Adult dose 300 mg PO immediately (chewed, not enteric-coated) for suspected ACS

Paediatric dose Not indicated for ACS in paediatrics

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

💊

Glyceryl Trinitrate (GTN)

Anginine® · Lycinate® · Nitrate vasodilator

Adult dose 600 micrograms SL every 5 minutes, up to 3 doses; reassess BP before each dose

Contraindication Systolic BP <90 mmHg; concurrent PDE5 inhibitor use within 24 h (sildenafil) or 48 h (tadalafil)

PBS status ✔ PBS General Benefit

Aortic Causes

Acute aortic dissection is the most critical vascular cause of thoracic back pain and demands immediate recognition. Stanford Type A (ascending aorta) dissections are surgical emergencies, while Type B (descending aorta) may be managed medically in uncomplicated cases. The classic presentation is sudden-onset, severe, tearing interscapular pain that may migrate as the dissection propagates. A blood pressure differential of >20 mmHg between arms, aortic regurgitation murmur, and pulse deficits are important clinical signs.

🚨

Suspect aortic dissection when: Sudden-onset tearing interscapular pain ± radiation, BP differential >20 mmHg between arms, pulse deficit, new aortic regurgitation murmur, mediastinal widening on CXR, or history of Marfan syndrome / bicuspid aortic valve / aortic aneurysm. Urgent CT aortogram is the investigation of choice.

💊

Labetalol

Trandate® · Combined α/β-blocker

Adult dose 20 mg IV bolus over 2 min; repeat 20–80 mg every 10 min (max 300 mg); or infusion 2 mg/min titrated to target HR <60 and SBP 100–120 mmHg

Paediatric dose 0.2–1 mg/kg/dose IV over 2 min; specialist guidance required

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

Oesophageal Causes

Oesophageal pathology may present with thoracic or interscapular pain. Important causes include:

Gastro-oesophageal reflux disease (GORD): Burning retrosternal or epigastric pain radiating to the interscapular region, worse after meals and when supine. Responds to proton pump inhibitor (PPI) therapy.
Boerhaave syndrome (spontaneous oesophageal rupture): Severe thoracic pain following forceful vomiting, with subcutaneous emphysema, pneumomediastinum, and left pleural effusion on CXR. Surgical emergency with high mortality if untreated within 24 hours.
Oesophageal spasm: Intermittent severe retrosternal or interscapular chest pain that may mimic ACS. Diagnosed on oesophageal manometry. May respond to calcium channel blockers or nitrates.
Oesophageal carcinoma: Progressive dysphagia, weight loss, and thoracic/back pain in advanced disease. Requires urgent gastroscopy.

💊

Pantoprazole

Somac® · Proton pump inhibitor

Adult dose 40 mg PO daily, 30 min before breakfast for 4–8 weeks

Paediatric dose ≥2 years: 0.5–1 mg/kg/day PO (max 40 mg); specialist guidance recommended

Renal adjustment No adjustment required

PBS status ✔ PBS General Benefit

Gall Bladder & Hepatobiliary Causes

Biliary colic and acute cholecystitis characteristically refer pain to the right upper quadrant with radiation to the right infrascapular region and right shoulder tip (via phrenic nerve irritation). The pain of biliary colic typically occurs postprandially (especially after fatty meals), is steady (not colicky despite the name), lasts 30 minutes to several hours, and resolves spontaneously. Acute cholecystitis presents with persistent RUQ pain, fever, Murphy sign positive, and leucocytosis.

Right upper quadrant ultrasound is the first-line investigation (sensitivity ~88% for gallstones). Liver function tests and lipase should be requested to assess for choledocholithiasis and pancreatitis respectively. Acute cholecystitis warrants surgical consultation for early laparoscopic cholecystectomy within 72 hours of symptom onset, in line with Australian guidelines.

💡

Differential clue: Right infrascapular pain that is aggravated by fatty food intake and associated with nausea should prompt investigation for biliary pathology even if the patient describes it as "back pain."

Red Flags for Thoracic Back Pain

Red flags in thoracic back pain serve as indicators of potentially serious underlying pathology. The presence of one or more red flags mandates urgent investigation and, where appropriate, specialist referral. Red flags should be assessed in combination rather than in isolation.

Red-Flag Categories

Malignancy

Neoplastic Red Flags

History of cancer (breast, lung, prostate, renal, thyroid, colorectal), unexplained weight loss >5 kg in 3 months, pain worse at night / at rest, age >50 at first presentation, failure to improve with conservative management after 4–6 weeks.

Investigation: MRI thoracic spine ± whole-body bone scan

Infection

Infectious Red Flags

Fever >38°C, IV drug use, recent spinal procedure or surgery, immunosuppression (HIV, biologics, chemotherapy, chronic corticosteroids), concurrent urinary tract or skin infection, elevated inflammatory markers (CRP >50, ESR >40).

Investigation: FBC, CRP, ESR, blood cultures ×2, MRI thoracic spine

Fracture

Fracture Red Flags

Significant trauma (fall from height, MVA), minor trauma in osteoporotic patient, prolonged corticosteroid use (>3 months), age >65, bone densitometry T-score ≤ −2.5, acute onset of focal thoracic pain.

Investigation: Plain XR thoracic spine (AP + lateral); CT if XR inconclusive

Neurological

Myelopathy / Cord Compression

Progressive bilateral lower limb weakness, gait ataxia, saddle anaesthesia, new urinary retention or incontinence, upper motor neuron signs (hyperreflexia, extensor plantars, clonus), sensory level.

Investigation: Urgent MRI thoracic spine; surgical referral

Vascular

Aortic Dissection Red Flags

Sudden-onset severe tearing interscapular pain, BP differential >20 mmHg between arms, pulse deficit, new aortic regurgitation, mediastinal widening on CXR, Marfan syndrome or connective tissue disorder.

Investigation: Urgent CT aortogram; call vascular/cardiothoracic surgery

Inflammatory

Spondyloarthropathy Red Flags

Age of onset <40, morning stiffness >30 minutes, improvement with exercise, worsening with rest, alternating buttock pain, enthesitis, dactylitis, uveitis, psoriasis, inflammatory bowel disease, HLA-B27 positive.

Investigation: HLA-B27, CRP, ESR, sacroiliac joint imaging

🚨

Cauda equina / cord compression: New-onset bilateral lower limb neurological signs, saddle anaesthesia, or bladder/bowel dysfunction in the context of thoracic back pain is a surgical emergency. Arrange urgent MRI and neurosurgical or spinal unit referral within 24 hours (ideally same-day).

Investigations Guided by Red Flags

Essential 12-lead ECG Any patient with cardiovascular risk factors and thoracic back pain. Perform within 10 minutes. Assess ST changes, reciprocal changes, posterior leads (V7–V9) if posterior MI suspected.

Essential Troponin (high-sensitivity) hs-cTnT or hs-cTnI at presentation and 2–3 hours post-onset. MBS item 66532. Available in all Australian EDs and most regional hospitals.

Available CRP & ESR Elevated CRP (>50 mg/L) and ESR (>40 mm/hr) suggest infection, malignancy, or inflammatory aetiology. MBS item 65070. Available in all Australian pathology services.

Available FBC with differential Leucocytosis suggests infection; anaemia may indicate chronic disease or malignancy; thrombocytopenia in disseminated malignancy. MBS item 65060.

Available Thoracic spine XR (AP + lateral) First-line for suspected fracture, Scheuermann disease, or destructive bony lesion. MBS item 58110. Available in all Australian radiology practices including rural/remote centres.

Referral MRI thoracic spine Gold standard for cord compression, disc prolapse, infection, and malignancy. MBS items 63201/63206. Available in major centres; may require transfer from rural/remote areas. Bulk-billed through public hospital for urgent indications.

Referral CT aortogram Investigation of choice for suspected aortic dissection. Available in all major EDs. Requires IV contrast; assess renal function (eGFR) prior.

Available RUQ ultrasound First-line for biliary colic and cholecystitis. MBS item 55302. Sensitivity ~88% for gallstones. Available in most radiology practices.

Costovertebral Joint Dysfunction

Costovertebral joint dysfunction (also termed costovertebral joint syndrome or thoracic facet syndrome) is a common and under-diagnosed cause of thoracic back pain in Australian primary care. It involves hypomobility, subluxation, or inflammatory irritation of the costovertebral or costotransverse joints, most frequently affecting the T4–T8 segments where rib mobility is greatest.

Anatomy & Pathophysiology

Each rib articulates with the thoracic vertebral column at two sites:

Costovertebral joint: The rib head articulates with the facets on the vertebral bodies of two adjacent thoracic vertebrae and the intervening intervertebral disc.
Costotransverse joint: The rib tubercle articulates with the transverse process of the corresponding thoracic vertebra (ribs 1–10 only).

These joints are richly innervated by the lateral branches of the posterior primary rami of the thoracic spinal nerves. Dysfunction may arise from repetitive microtrauma (poor posture, prolonged computer use), acute trauma (coughing paroxysm, forceful sneezing), degenerative changes, or systemic inflammatory conditions. Segmental stiffness leads to compensatory hypermobility at adjacent segments, perpetuating a cycle of pain and dysfunction.

Clinical Presentation

Unilateral or bilateral paravertebral pain, typically sharp or aching
Pain worsened by deep inspiration, coughing, sneezing, or twisting movements
Localised tenderness on palpation of the costovertebral angle or paravertebral region
Pain may radiate around the chest wall in a dermatomal or pseudo-dermatomal pattern
Reduced thoracic rotation and lateral flexion on the affected side
Positive Costovertebral Compression Test: pain reproduced with gentle posterior-to-anterior pressure over the rib angle with the patient prone

Diagnostic Confirmation

Diagnosis is primarily clinical. Key features distinguishing costovertebral joint dysfunction from serious pathology include:

Pain reproducible on palpation and specific provocation manoeuvres
Absence of red flags (see Red Flags section above)
Response to local anaesthetic injection of the costovertebral joint (diagnostic-therapeutic block) — MBS item 18360 may apply
Imaging is typically normal; available to exclude other pathology

Management

Management follows a stepped approach:

Education & Activity Modification

Reassurance of benign nature, avoidance of aggravating postures, ergonomic advice for workstation setup, graduated return to normal activity.

Pharmacotherapy

Paracetamol 1 g PO QID PRN ± short course of NSAIDs (e.g., naproxen 250–500 mg PO BD for 5–7 days). Avoid opioids. Short-course muscle relaxant (diazepam 2–5 mg PO TDS for ≤5 days) if muscle spasm prominent — use with caution.

Manual Therapy

Thoracic spinal manipulation or mobilisation by a physiotherapist, osteopath, or chiropractor. Evidence supports short-term benefit for pain and range of motion (Australian Physiotherapy Association guidelines).

Interventional

Costovertebral or costotransverse joint injection (corticosteroid + local anaesthetic) for refractory cases. Performed under fluoroscopic or ultrasound guidance. Refer to pain medicine specialist or sports medicine physician.

💊

Paracetamol

Panadol® · Panamax® · Analgesic

Adult dose 500 mg–1 g PO every 4–6 hours PRN (max 4 g/day)

Paediatric dose 15 mg/kg/dose PO every 4–6 hours PRN (max 60 mg/kg/day)

Route Oral (also IV, rectal)

Renal adjustment eGFR <30: extend interval to every 6 hours; max 2 g/day if eGFR <10

Hepatic adjustment Avoid or reduce dose (max 2 g/day) in severe hepatic impairment or chronic alcohol use

PBS status ✔ PBS General Benefit

💊

Naproxen

Naprosyn® · Inza® · NSAID

Adult dose 250–500 mg PO BD with food for 5–7 days

Paediatric dose ≥2 years: 5–7 mg/kg/dose PO BD (max 1 g/day); specialist guidance recommended

Route Oral

Renal adjustment Avoid if eGFR <30 mL/min

Hepatic adjustment Use with caution; avoid in severe hepatic impairment

PBS status ✔ PBS General Benefit

💊

Diazepam

Ducene® · Valium® · Benzodiazepine

Adult dose 2–5 mg PO TDS for ≤5 days (muscle spasm only)

Paediatric dose Not recommended for musculoskeletal spasm in children

Duration ≤5 days to minimise dependence risk

Renal adjustment No adjustment required; use with caution in elderly

Hepatic adjustment Reduce dose by 50% in severe hepatic impairment

PBS status ⚠ PBS Authority Required

Investigations

Investigation of thoracic back pain is guided by the clinical context, red-flag presence, and diagnostic model stage. Most patients presenting with mechanical thoracic back pain and no red flags do not require imaging and should be managed conservatively for 4–6 weeks before considering further investigation.

First-Line Investigations (Primary Care)

Investigation	MBS Item	Indication	Availability
Thoracic spine XR (AP + lateral)	58110	Suspected fracture, Scheuermann disease, bony destructive lesion	All radiology practices nationally
12-lead ECG	11700	CV risk factors; exclude ACS, pericarditis	All GP practices, all EDs
hs-Troponin	66532	Suspected ACS	All pathology services
FBC, CRP, ESR	65060, 65070	Suspected infection, malignancy, inflammation	All pathology services
LFTs, lipase	66515, 66545	Suspected biliary or pancreatic pathology	All pathology services
RUQ ultrasound	55302	Suspected gallstones / cholecystitis	Most radiology practices

Second-Line / Specialist Investigations

Investigation	MBS Item	Indication	Availability
MRI thoracic spine	63201/63206	Cord compression, disc prolapse, infection, malignancy, neuro deficit	Major centres; transfer may be required from rural/remote
CT thoracic spine	56810	Occult fracture, bony detail of destructive lesion	Most radiology practices
CT aortogram	57360	Suspected aortic dissection	All major EDs
Bone densitometry (DXA)	12312	Suspected osteoporosis / compression fracture	Most radiology practices
Bone scan (SPECT/CT)	61405	Metastatic bone disease screening	Nuclear medicine facilities (major centres)

Management of Musculoskeletal Thoracic Back Pain

Once red flags have been excluded and a musculoskeletal cause confirmed, management of thoracic back pain follows a conservative, evidence-based approach aligned with Australian Therapeutic Guidelines and the National Health and Medical Research Council (NHMRC) recommendations for acute musculoskeletal pain.

First-Line Management

Patient education: Explain the benign nature of most thoracic back pain, expected natural history (improvement within 2–6 weeks), and importance of maintaining normal activity.
Activity modification: Avoid prolonged bed rest (do not recommend >48 hours). Encourage graduated return to work and normal activities. Ergonomic assessment for desk workers.
Paracetamol: 500 mg–1 g PO every 4–6 hours PRN (max 4 g/day). First-line analgesic for most patients.
NSAIDs: Naproxen 250–500 mg PO BD or ibuprofen 200–400 mg PO TDS with food for 5–7 days. Use lowest effective dose; concurrent PPI (e.g., omeprazole 20 mg daily) if GI risk factors present.
Heat therapy: Superficial heat packs applied for 15–20 minutes may provide symptomatic relief.

Second-Line Management

Physiotherapy: Manual therapy (thoracic mobilisation/manipulation), targeted strengthening exercises for thoracic extensors and scapular stabilisers, postural retraining. Evidence supports short-term benefit.
Muscle relaxants: Diazepam 2–5 mg PO TDS for ≤5 days. Use sparingly due to sedation and dependence risk. Avoid in elderly and those at fall risk.
Acupuncture: May be considered as adjunctive therapy for chronic thoracic back pain.

Third-Line / Referral

Pain medicine specialist: For refractory cases; costovertebral joint injections, medial branch blocks, or radiofrequency denervation.
Rheumatologist: If inflammatory spondyloarthropathy suspected.
Spinal surgeon / Neurosurgeon: Thoracic disc prolapse with myelopathy, spinal instability, or cord compression.
Psychologist: Cognitive behavioural therapy (CBT) for chronic pain with significant yellow-flag burden.

⚠️

Avoid opioid initiation: Opioid analgesics are not recommended for acute or chronic musculoskeletal thoracic back pain per Australian Therapeutic Guidelines. If opioids have been initiated, develop an early weaning plan. Refer to the RACGP Opioid Prescribing Guide for deprescribing support.

Special Populations

🤰

Pregnancy

Thoracic back pain in pregnancy: Common in the 2nd and 3rd trimesters due to altered thoracic kyphosis, increased breast weight, and hormonal ligamentous laxity.

Paracetamol Safe in all trimesters. First-line analgesic.

Ibuprofen Avoid in 3rd trimester (risk of premature ductus arteriosus closure, oligohydramnios). Use with caution in 2nd trimester only if benefit outweighs risk.

Naproxen Same restrictions as ibuprofen. Avoid in 3rd trimester.

Physiotherapy and gentle stretching are preferred non-pharmacological approaches. Referral to a women's health physiotherapist is recommended.

👶

Paediatrics

Thoracic back pain in children is uncommon and warrants careful evaluation. Consider Scheuermann disease (adolescent kyphosis, age 12–17), spinal infection, malignancy (leukaemia, lymphoma), and sports-related costovertebral injury.

Paracetamol 15 mg/kg/dose PO every 4–6 hours PRN (max 60 mg/kg/day).

Ibuprofen ≥3 months: 5–10 mg/kg/dose PO TDS with food (max 30 mg/kg/day or 1.2 g/day).

Any child with thoracic back pain and red flags (fever, weight loss, night pain, neurological signs) should be referred for urgent paediatric assessment and MRI. Avoid benzodiazepines in children.

🧓

Elderly

Osteoporotic compression fractures are the most common cause of acute thoracic back pain in patients >65 years. May occur with minimal or no trauma. Onset is often sudden with localised mid-thoracic pain.

Paracetamol Preferred first-line. Reduce max dose to 3 g/day if low body weight (<50 kg).

NSAIDs Use with extreme caution — increased GI bleed and cardiovascular risk. If required, use lowest dose for ≤5 days with PPI cover.

Bone densitometry (DXA) should be arranged for all patients >50 with thoracic compression fracture. Initiate osteoporosis treatment (e.g., alendronate 70 mg PO weekly — PBS Authority Required) to prevent further fractures.

🫘

Renal Impairment

NSAIDs are contraindicated if eGFR <30 mL/min. Use paracetamol as first-line analgesic. If eGFR <10, reduce paracetamol to max 2 g/day.

Diazepam Active metabolites accumulate in renal failure — use with extreme caution or avoid.

Contrast CT (for suspected aortic dissection or fracture): Pre-hydrate with IV normal saline; check eGFR. Use low-osmolar or iso-osmolar contrast if eGFR 30–45. Avoid if eGFR <30 unless life-threatening indication.

🫁

Hepatic Impairment

Paracetamol Reduce max dose to 2 g/day in severe hepatic impairment (Child-Pugh C) or chronic alcohol use (≥3 standard drinks/day).

NSAIDs are generally avoided in severe hepatic impairment due to increased bleeding risk (coagulopathy) and renal vasoconstriction.

Diazepam Reduce dose by 50%; prolonged half-life in hepatic impairment.

Investigate LFTs if right-sided thoracic/ infrascapular pain — biliary pathology may be the cause of pain.

🛡️

Immunocompromised

Vertebral osteomyelitis and epidural abscess are significantly more common in immunocompromised patients (HIV, biologic therapy, chemotherapy, chronic corticosteroids, organ transplant). Presentation may be atypical with blunted inflammatory response.

Thoracic back pain + fever in an immunocompromised patient should be investigated with FBC, CRP, ESR, blood cultures ×2, and urgent MRI thoracic spine.

Corticosteroid-induced osteoporosis: Patients on ≥3 months of prednisolone ≥7.5 mg/day are at high risk for thoracic vertebral compression fracture. Bone protection (calcium, vitamin D, bisphosphonate) should be co-prescribed from corticosteroid initiation.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Epidemiology

Aboriginal and Torres Strait Islander Australians experience musculoskeletal pain at 1.4–2 times the rate of non-Indigenous Australians (AIHW 2023). Thoracic back pain related to osteoporosis is more prevalent due to higher rates of vitamin D deficiency, lower DXA screening rates, and higher prevalence of chronic kidney disease (which accelerates bone loss).

Red-flag awareness

Delayed presentation means that serious causes of thoracic back pain (including spinal infection, vertebral osteomyelitis, and advanced malignancy) may be diagnosed at a later stage. TB-related spinal disease (Pott disease) remains relevant in some remote communities. Active case-finding and yarning-based health assessments (MBS Item 715) provide opportunities for early identification.

Remote & rural access

MRI and specialist services are limited in remote and very remote communities. Royal Flying Doctor Service (RFDS) and retrieval services provide emergency aeromedical transfer for suspected cord compression or aortic dissection. Telehealth consultations with spinal specialists can facilitate timely assessment. Plain XR is available in most Aboriginal Community Controlled Health Services (ACCHS).

Cultural safety

Use culturally safe communication approaches: yarning, visual pain assessment tools, and involving Aboriginal and Torres Strait Islander health workers in consultations. Acknowledge the impact of intergenerational trauma, grief, and social determinants (overcrowded housing, manual labour) on pain experience and chronicity. Gender-sensitive examination practices are essential — request a chaperone where appropriate.

Pharmacological considerations

Ensure access to PBS medications through Closing the Gap (CTG) PBS Co-Payment Program — eligible patients pay a reduced co-payment or

📋 Key Information Summary

📋

Haemorrhoids are the most common anorectal condition in Australian general practice, affecting up to 40% of adults over 50 years; most are managed conservatively with fibre supplementation, topical agents, and lifestyle modification.
Anal fissure presents with sharp pain on defecation and bright red rectal bleeding; chronic fissures (≥6 weeks) require topical GTN or diltiazem ointment before surgical consideration.
Perianal abscess is a surgical emergency requiring prompt incision and drainage; antibiotics alone are insufficient — up to 50% develop a fistula-in-ano.
Pilonidal sinus predominantly affects young males (15–30 years); acute abscess requires drainage; definitive surgery (excision ± flap) is reserved for recurrent or chronic disease.
Faecal incontinence affects 2–15% of community-dwelling Australians and is significantly underreported; obstetric sphincter injury is the leading cause in women.
Rectal prolapse in adults usually requires surgical repair (e.g., ventral mesh rectopexy); in children, it is almost always self-limiting and managed conservatively.
Rectal bleeding demands systematic evaluation — while haemorrhoids are the most common cause, always exclude colorectal cancer, inflammatory bowel disease, and angiodysplasia, especially in patients aged ≥45 years.
Red-flag features — change in bowel habit, weight loss, iron-deficiency anaemia, new onset age ≥45, or family history of colorectal cancer — warrant urgent colonoscopy referral.
Digital rectal examination (DRE) and rigid/flexible sigmoidoscopy are essential first-line investigations in primary care for all anorectal presentations.
Aboriginal and Torres Strait Islander peoples have higher rates of colorectal cancer with later-stage presentation and lower screening participation; culturally safe engagement and proactive referral are critical.
Stool softeners (e.g., macrogol 3350, docusate) are a cornerstone adjunct in nearly every anorectal condition to reduce straining and recurrence.
When to refer urgently: large or circumferential haemorrhoids (Grade III–IV), chronic fissure unresponsive to 8 weeks of medical therapy, perianal abscess with systemic sepsis, full-thickness rectal prolapse, or any rectal bleeding with red-flag features.

Introduction & Australian Epidemiology

Anorectal disorders encompass a broad spectrum of benign and malignant conditions affecting the anal canal, perianal skin, and distal rectum. These conditions are exceedingly common in Australian general practice, accounting for a significant proportion of surgical referrals and ambulatory presentations. Despite their prevalence, many patients delay seeking care due to embarrassment, leading to diagnostic delays and avoidable complications.

In Australia, haemorrhoids affect an estimated 30–40% of adults over the age of 50, with symptomatic haemorrhoids representing one of the most frequent reasons for gastroenterological and surgical consultation. Anal fissure has an annual incidence of approximately 1 in 350 adults, with a bimodal distribution peaking in young adults and middle-aged women. Perianal abscess occurs predominantly in males aged 20–40 years, with an annual incidence of roughly 10 per 100,000 population.

Colorectal cancer remains Australia's second most common cause of cancer-related mortality, with over 15,000 new diagnoses annually (Australian Institute of Health and Welfare, 2023). Rectal bleeding is the presenting symptom in up to 35% of colorectal cancers, underscoring the importance of systematic evaluation rather than reflex attribution to benign causes.

This article provides a comprehensive Australian primary care and surgical perspective on the diagnosis and management of common anorectal disorders, including anal fissure, haemorrhoids, perianal abscess, pilonidal sinus, faecal incontinence, rectal prolapse, and rectal bleeding. Management recommendations are aligned with Therapeutic Guidelines (eTG), the Royal Australian College of General Practitioners (RACGP), the Colorectal Surgical Society of Australia and New Zealand (CSSANZ), and relevant Australian and international consensus statements.

⚠️

Clinical Pearl: Never attribute rectal bleeding to haemorrhoids without a thorough clinical assessment including DRE and, where indicated, endoscopic evaluation. Missed colorectal cancer in the context of "haemorrhoidal bleeding" is a recognised source of medicolegal risk in Australian general practice.

Anal Fissure & Haemorrhoids

Anal Fissure

An anal fissure is a linear tear or ulcer in the squamous epithelium of the anal canal, distal to the dentate line. It is one of the most common causes of anorectal pain and rectal bleeding in younger adults. The pathophysiology involves a cycle of internal anal sphincter hypertonia, reduced anodermal blood flow, and impaired healing.

Classification

Feature	Acute Fissure (<6 weeks)	Chronic Fissure (≥6 weeks)
Appearance	Superficial, linear tear; well-demarcated edges	Deep ulcer; sentinel skin tag (distal), hypertrophied anal papilla (proximal)
Location	Posterior midline (80–90%)	Posterior midline; anterior midline in women
Symptoms	Sharp pain on defecation, bright red blood on paper	Persistent pain, spasm, bleeding, cyclical pattern
First-line Rx	Conservative (fibre, sitz baths, topical GTN)	Topical GTN 0.2–0.4% or diltiazem 2% ointment ± botulinum toxin

Management of Anal Fissure

Conservative measures (all patients)

Dietary fibre supplementation (psyllium husk 3–6 g/day or ispaghula), adequate oral hydration (≥1.5 L/day), warm sitz baths (10–15 min BD), stool softeners (macrogol 3350 or docusate sodium), and avoidance of straining.

Pharmacological (if conservative measures fail at 2–4 weeks)

Glyceryl trinitrate (GTN) 0.2–0.4% ointment applied perianally BD for 8 weeks, OR diltiazem 2% ointment BD for 8 weeks (less headache). Compounding pharmacy often required for GTN; diltiazem 2% available as Rectogesic® (0.2% GTN is PBS-listed; 0.4% may require authority).

Second-line / specialist referral

Botulinum toxin A injection (20 units into internal sphincter) performed by colorectal surgeon, or lateral internal sphincterotomy (gold standard surgical cure rate 90–95%, but risk of flatus/faecal incontinence ~5–10%). Reserved for refractory cases.

💊

Glyceryl Trinitrate (GTN) 0.2% Ointment

Rectogesic® · Topical nitric oxide donor

Adult dose Apply 1 cm ribbon to perianal skin BD (morning and night) for 8 weeks

Paediatric dose Not routinely recommended in children; use conservative measures first

Common side effects Headache (up to 50%), dizziness, local irritation

Renal adjustment None required

PBS status ✔ PBS General Benefit

💊

Diltiazem 2% Ointment

Compounded · Calcium channel blocker (topical)

Adult dose Apply 1 cm ribbon perianally BD for 8 weeks

Advantage Less headache than GTN; similar efficacy

Renal adjustment None required

PBS status ✘ Not PBS-listed (compounded)

Haemorrhoids

Haemorrhoids (piles) are swollen vascular cushions in the anal canal arising from the internal or external haemorrhoidal plexus. They are classified by grade and position (internal vs external vs mixed). Risk factors include chronic constipation, straining, pregnancy, low-fibre diet, portal hypertension, and obesity.

Classification of Internal Haemorrhoids

Grade I

Non-prolapsing

Haemorrhoids remain above the dentate line; visible only on proctoscopy. May cause painless bright red bleeding.

Setting: GP — conservative management

Grade II

Prolapse with straining, spontaneous reduction

Prolapse through the anal canal on defecation or straining; reduces spontaneously. Bleeding, pruritus, and mucous discharge common.

Setting: GP ± specialist for rubber band ligation

Grade III

Prolapse requiring manual reduction

Prolapse requiring digital replacement. May be associated with thrombosis, significant bleeding, and discomfort.

Setting: Specialist referral — banding, sclerotherapy, or surgery

Grade IV

Irreducible prolapse

Permanently prolapsed, cannot be reduced. Risk of strangulation, gangrene, and massive haemorrhage.

Setting: Urgent surgical referral — haemorrhoidectomy

Management of Haemorrhoids

Conservative (Grade I–II)

High-fibre diet (≥30 g/day), fibre supplements (psyllium, sterculia), adequate fluids, stool softeners, avoidance of straining and prolonged sitting on the toilet, warm sitz baths. Topical preparations (local anaesthetic ± hydrocortisone) for short-term symptom relief (≤7 days).

Office-based procedures (Grade II–III)

Rubber band ligation (RBL) — most common, 70–80% cure rate; sclerotherapy (phenol in oil injection); infrared coagulation. Performed in outpatient colorectal clinic under direct vision.

Surgical (Grade III–IV or failed conservative)

Haemorrhoidectomy (excisional — Milligan-Morgan or Ferguson technique) — gold standard for advanced disease. Stapled haemorrhoidopexy (PPH) — less pain but higher recurrence rate. Haemorrhoidal artery ligation (THD/Doppler-guided) — emerging option. MBS item 30740.

🚨

Thrombosed external haemorrhoid: Presents as an acutely painful, blue-purple perianal lump within 48–72 hours of onset. If seen within 72 hours, excision of the thrombosed haemorrhoid under local anaesthesia provides immediate relief. If >72 hours, conservative management (analgesia, ice, stool softeners) is preferred as the thrombus begins to organise.

💊

Macrogol 3350 (Polyethylene Glycol)

Movicol® · Osmotic laxative / stool softener

Adult dose 1–3 sachets daily, dissolved in 125 mL water per sachet; titrate to soft stool

Paediatric dose ½–1 sachet daily (age <6 years); 1–2 sachets daily (6–12 years)

Renal adjustment Use with caution in severe renal impairment (electrolyte content)

PBS status ✔ PBS General Benefit

💊

Lidocaine + Hydrocortisone Topical

Proctosedyl® · Local anaesthetic + anti-inflammatory

Adult dose Apply to affected area BD and after each bowel motion for ≤7 days

Note Short-term use only; chronic use may cause skin atrophy and sensitisation

PBS status ✔ PBS General Benefit

Perianal Abscess & Pilonidal Sinus

Perianal Abscess

A perianal abscess arises from infection of the anal glands (cryptoglandular theory) at the level of the dentate line, tracking into the perianal, ischiorectal, intersphincteric, or supralevator spaces. It is the most common anorectal emergency and is approximately twice as common in males than females. Up to 50% of patients who develop a perianal abscess will subsequently develop a fistula-in-ano.

Classification by Anatomical Space

Type	Frequency	Clinical Features	Management
Perianal	~60%	Superficial, painful swelling adjacent to the anus; visible erythema and fluctuance	I&D under local anaesthesia in ED or office
Ischiorectal	~20%	Deep, diffuse perineal swelling; systemic illness; less visible externally	I&D under GA or regional anaesthesia
Intersphincteric	~5%	Severe anal pain; minimal external signs; may be palpable on DRE	Specialist drainage; MRI if equivocal
Supralevator	<5%	Pelvic pain; may mimic pelvic pathology; often iatrogenic or Crohn's-related	Specialist drainage; CT/MRI pelvis
Fournier's gangrene	Rare	Necrotising fasciitis of the perineum; rapidly progressive, crepitus, sepsis, multi-organ failure	Immediate surgical debridement + broad-spectrum IV antibiotics (meropenem + vancomycin); ICU

🚨

Fournier's gangrene: A life-threatening necrotising fasciitis of the perineum. Presents with rapidly spreading erythema, crepitus, pain disproportionate to examination, and systemic sepsis. Mortality 20–40%. Requires immediate surgical debridement, broad-spectrum IV antibiotics, and ICU admission. Do not delay for imaging if clinical suspicion is high.

⚠️

Immunocompromised patients: Perianal abscess in patients with diabetes mellitus, HIV/AIDS, neutropenia, or those on immunosuppressants (including biologics) may present atypically and progress rapidly. Always consider Crohn's disease in recurrent or complex perianal sepsis.

Management of Perianal Abscess

Incision and drainage (I&D) is the definitive treatment for all perianal abscesses. Antibiotics alone are inadequate. The procedure involves:

Incision as close to the anal verge as possible (to minimise fistula tract length)
Breakdown of all loculations with digital exploration
Excision of overlying skin ellipse (to prevent premature closure)
Packing with saline-soaked gauze or wound wick; sitz baths from 48 hours
Search for internal opening (Goodsall's rule for fistula prediction)

Antibiotics are NOT routinely required for simple perianal abscess after adequate I&D. Reserve antibiotics for:

Surrounding cellulitis (erythema >2 cm from wound edge)
Systemic signs (fever >38°C, tachycardia, raised WCC/CRP)
Immunocompromised patients
Valvular heart disease or prosthetic material (endocarditis prophylaxis per current guidelines)
Fournier's gangrene or necrotising infection

💊

Amoxicillin + Clavulanate

Augmentin® · Beta-lactam / beta-lactamase inhibitor

Adult dose (oral) 875/125 mg PO BD for 5–7 days (cellulitis adjunct)

Adult dose (IV) 1.2 g IV TDS (severe infection)

Paediatric dose 25/3.6 mg/kg PO BD or 30/4.5 mg/kg IV TDS

Renal adjustment eGFR 10–30: 875/125 mg PO BD; eGFR <10: 500/125 mg PO BD

PBS status ✔ PBS General Benefit

💊

Metronidazole

Flagyl® · Nitroimidazole antibiotic (anaerobic cover)

Adult dose 400 mg PO TDS for 5–7 days (combined with amoxicillin + clavulanate)

Paediatric dose 7.5 mg/kg PO/IV TDS (max 400 mg/dose)

Important Avoid alcohol (disulfiram-like reaction); metallic taste; peripheral neuropathy with prolonged use

PBS status ✔ PBS General Benefit

Pilonidal Sinus

Pilonidal disease is a chronic inflammatory condition of the natal cleft, most common in young males aged 15–30 years with risk factors including hirsutism, obesity, sedentary occupation, and prolonged sitting. The pathogenesis involves hair follicle penetration creating a foreign-body granulomatous reaction and secondary infection.

Management

Acute pilonidal abscess

Incision and drainage ± excision of the sinus tract in the same sitting. Off-midline incision preferred to reduce recurrence. Hair removal from the natal cleft (shaving or laser). Wound left open to heal by secondary intention.

Chronic / recurrent pilonidal sinus

Definitive surgical excision — wide local excision with healing by secondary intention, Limberg flap (rhomboid flap), or Bascom cleft lift procedure. Flap techniques have lower recurrence rates (2–5% vs 10–30%) and faster return to work.

Conservative (limited disease)

Regular hair removal, meticulous perineal hygiene, phenol application for small tracts, sinus excision (pit-picking technique). Most appropriate for first episode with minimal symptoms.

Anal Incontinence & Rectal Prolapse

Anal (Faecal) Incontinence

Faecal incontinence (FI) is defined as the involuntary loss of solid or liquid stool. It affects 2–15% of community-dwelling Australians, with prevalence rising to 50% in residential aged care facilities. Despite its high prevalence, FI is significantly underreported due to patient embarrassment. It is a leading cause of nursing home admission in the elderly.

Aetiology

Category	Causes
Sphincter disruption	Obstetric injury (3rd/4th degree perineal tear — most common in women), iatrogenic (sphincterotomy, fistula repair, haemorrhoidectomy), trauma
Neurological	Pudendal neuropathy (chronic straining, obstetric, diabetes), spinal cord injury, cauda equina, multiple sclerosis, stroke
Structural	Rectal prolapse, rectocele, large internal haemorrhoids
Functional	Overflow incontinence (faecal impaction), diarrhoea-predominant IBS, cognitive impairment
Inflammatory	Ulcerative colitis, Crohn's disease, radiation proctitis

Assessment

History: Type of incontinence (urge vs passive), frequency, severity, impact on QoL, obstetric history, surgical history, bowel habit, medication review (laxatives, metformin, PPIs).
Examination: Perianal inspection (skin excoriation, scarring, prolapse), DRE (resting and squeeze tone, sensation), perineal descent assessment.
Validated scoring: Wexner (Cleveland Clinic) Incontinence Score or St Mark's (Vaizey) Score for severity grading.
Specialist investigations: Endoanal ultrasound (gold standard for sphincter defects), anorectal manometry, pudendal nerve terminal motor latency (PNTML), defecating proctography or MRI defecography.

Available

Endoanal Ultrasound

Gold standard for internal and external sphincter defects. Available at most tertiary hospitals. MBS item 55068.

Referral

Anorectal Manometry

Assesses resting/squeeze pressures and rectal sensation. Available at specialist GI physiology labs. MBS item 12250.

Referral

MRI Defecography

Dynamic assessment of pelvic floor and rectal evacuation. Identifies rectocele, intussusception, and pelvic floor dyssynergia. MBS item 63536.

Available

Faecal Calprotectin

Excludes inflammatory bowel disease as an underlying cause. MBS item 66821 (bulk-billed in most settings).

Management of Faecal Incontinence

Conservative (all patients)

Bowel habit optimisation (fibre, fluids, stool bulking agents), toilet timing/scheduled toileting, pelvic floor physiotherapy (biofeedback for 3–6 months), skin care (barrier creams, incontinence pads), treatment of diarrhoea or constipation. Referral to continence nurse specialist (Continence Foundation of Australia: 1800 33 00 66).

Pharmacological

Loperamide 2–4 mg PRN (max 16 mg/day) for urge incontinence with loose stool; increases internal sphincter tone. Codeine phosphate 30–60 mg PRN as second-line. Avoid bulk-forming agents with loose stool (may worsen).

Specialist / Surgical

Sphincter repair (overlap sphincteroplasty for obstetric defect — best outcomes within 6 months of injury), sacral nerve stimulation (SNS/neuromodulation — effective for idiopathic and some sphincter defects), injectable bulking agents (Solesta®), artificial bowel sphincter, magnetic anal sphincter (FENIX®), antegrade colonic irrigation (ACE procedure).

Rectal Prolapse

Rectal prolapse is the circumferential protrusion of the full thickness of the rectal wall through the anal canal. It must be distinguished from mucosal prolapse (internal or external) and rectal intussusception.

Classification

Mucosal

Mucosal (partial) prolapse

Protrusion of rectal mucosa only; radial folds; common in children and elderly. Usually self-limiting in paediatric population.

Setting: GP — conservative in children; specialist if persistent

Full thickness

Complete (full-thickness) rectal prolapse

All layers of the rectal wall protrude; concentric folds; associated with faecal incontinence (50–75%), constipation (25–50%), and mucous discharge.

Setting: Specialist surgical referral — usually requires operative repair

Internal

Internal rectal intussusception / occult prolapse

Rectum telescopes into itself without external protrusion; causes obstructed defecation, incomplete evacuation, and may lead to full prolapse. Diagnosed by defecating proctography or MRI.

Setting: Specialist assessment — biofeedback or surgery

Management of Rectal Prolapse

Children: Almost always mucosal and self-limiting. Treat underlying cause (constipation, diarrhoea, cystic fibrosis screening). Conservative measures: high-fibre diet, stool softeners, avoidance of straining. If persistent beyond age 3–5, consider injection sclerotherapy or Thiersch procedure (rarely needed).
Adults — perineal approach: Delorme procedure (mucosal stripping + plication) or Altemeier procedure (perineal rectosigmoidectomy). Suitable for high-risk / elderly patients unable to tolerate abdominal surgery. MBS item 32086.
Adults — abdominal approach: Ventral mesh rectopexy (VMR) — current gold standard with low recurrence (~3–5%) and lower rates of new-onset constipation compared with posterior rectopexy. Resection rectopexy (Frykman-Goldberg) for patients with pre-existing constipation. Laparoscopic approach preferred. MBS item 32088/32090.

💊

Loperamide

Imodium® · Opioid receptor agonist (peripheral)

Adult dose 2 mg initially, then 2 mg after each loose stool (max 16 mg/day); maintenance 2–4 mg BD

Mechanism Slows transit, increases internal anal sphincter tone, improves stool consistency

Caution Avoid in active IBD flare, acute dysentery, or suspected bacterial enteritis without antibiotics

Renal adjustment None required

PBS status ✔ PBS General Benefit

Rectal Bleeding — Causes & Presentation

Rectal bleeding (haematochezia) is one of the most common gastrointestinal symptoms presenting to Australian general practice, affecting up to 15% of adults annually. While the majority of cases are attributable to benign anorectal conditions, rectal bleeding is the presenting symptom in approximately 35% of colorectal cancers. A systematic, risk-stratified approach to evaluation is essential.

Differential Diagnosis by Age and Presentation

Cause	Typical Presentation	Age Group	Key Features
Haemorrhoids	Painless bright red blood on paper, in toilet bowl, or on stool surface	30–65 years	Most common cause; associated with straining, constipation, pregnancy
Anal fissure	Sharp pain on defecation with streaks of bright red blood	15–45 years	Posterior midline position; sentinel tag in chronic cases
Colorectal cancer	Dark or bright red blood, change in bowel habit, weight loss, iron deficiency	≥45 years (screening age)	Must be excluded in all patients ≥45 with rectal bleeding; National Bowel Cancer Screening Program (NBCSP) from age 45 (reduced from 50 in 2024)
Inflammatory bowel disease	Bloody diarrhoea, mucus, urgency, weight loss, extraintestinal manifestations	15–35 years (UC); bimodal (Crohn's)	Faecal calprotectin elevated; colonoscopy with biopsies required
Diverticular bleeding	Sudden onset, painless, large volume maroon or dark red blood	>60 years	Most common cause of major lower GI bleeding in the elderly; usually self-limiting
Angiodysplasia	Recurrent, painless, low-volume bright red bleeding	>60 years	Right colon most common; associated with aortic stenosis (Heyde syndrome), CKD, anticoagulants
Infectious colitis	Bloody diarrhoea, abdominal cramps, fever	Any age	C. difficile, Salmonella, Shigella, Campylobacter, E. coli O157; stool MC+S essential
Solitary rectal ulcer syndrome	Bleeding, mucus discharge, straining, sensation of incomplete evacuation	Young–middle aged adults	Associated with rectal prolapse and paradoxical puborectalis contraction

Risk Stratification — When to Refer Urgently

🚨

Red-flag features requiring urgent investigation (colonoscopy within 30 days or urgent surgical referral):

Rectal bleeding in any patient ≥45 years without a benign anorectal cause confirmed on examination
Iron-deficiency anaemia (Hb <120 g/L in men, <115 g/L in women) with or without overt bleeding
Unintentional weight loss (>5% body weight in 6 months)
Change in bowel habit (new constipation or diarrhoea >6 weeks)
Family history of colorectal cancer (first-degree relative <55 years at diagnosis)
Positive faecal occult blood test (FOBT) from the National Bowel Cancer Screening Program
Abdominal or rectal mass on examination
Large-volume or haemodynamically significant bleeding

⚠️

Age threshold update: In 2024, the Australian Government lowered the NBCSP starting age from 50 to 45 years. All Australians aged 45–74 receive a free immunochemical faecal occult blood test (iFOBT) every 2 years. A positive test warrants colonoscopy referral within 30 days. GPs should encourage participation, particularly in under-screened populations.

Approach to Rectal Bleeding in Primary Care

History & red-flag assessment

Character of bleeding (colour, volume, frequency, relationship to stool), associated symptoms (pain, change in bowel habit, weight loss, tenesmus, mucus), family history, medication review (anticoagulants, NSAIDs, antiplatelets), prior episodes.

Examination

Vital signs (haemodynamic stability), abdominal examination, perianal inspection, DRE (tone, masses, fissure, haemorrhoids, stool colour), rigid sigmoidoscopy (identify source within 15–20 cm).

Initial investigations

FBC (anaemia, thrombocytopaenia), ferritin and iron studies (iron deficiency), CRP/ESR (inflammation), stool MC+S and C. difficile toxin if diarrhoea present, faecal calprotectin (exclude IBD), iFOBT if not already done.

Referral pathway

No red flags + confirmed benign source → treat locally and review in 4–6 weeks. Red flags or age ≥45 without confirmed benign cause → urgent colonoscopy referral (<30 days). Haemodynamic instability → ED / acute surgical admission. Ongoing bleeding with haemodynamic compromise → CT angiography ± interventional radiology embolisation.

Investigations Summary

Essential

Full Blood Count (FBC) + Iron Studies

Assess for iron-deficiency anaemia. Microcytic hypochromic picture suggests chronic blood loss. MBS item 66551 (FBC), 66573 (iron studies).

Essential

Digital Rectal Examination + Rigid Sigmoidoscopy

Identifies the source of bleeding in up to 70% of cases. Can be performed in GP rooms. MBS item 104 (DRE), 105 (sigmoidoscopy).

Available

Faecal Calprotectin

Screening test for IBD. Sensitivity ~95%, specificity ~80% for IBD. Levels >250 μg/g strongly suggest IBD. MBS item 66821.

Available

Immunochemical FOBT (iFOBT)

NBCSP screening test; also available on request. More sensitive than older guaiac-based tests. MBS item 66777 (not routinely billed; NBCSP is free).

Referral

Colonoscopy

Gold standard for visualising the entire colon and rectum with biopsy capability. Required for red-flag symptoms, positive FOBT, suspected IBD or cancer. MBS item 32222.

Referral

CT Angiography / Interventional Embolisation

For acute, haemodynamically significant lower GI bleeding where colonoscopy cannot identify the source. Interventional radiology for selective embolisation. MBS item 57353 (CT angiography).

Monitoring

0–2 weeks

Initial follow-up after diagnosis: assess response to conservative measures (fibre, sitz baths, topical agents). Confirm bleeding has settled. Review FBC and iron studies if anaemic.

4–6 weeks

Re-assess fissure healing (if on topical GTN/diltiazem). Review haemorrhoid symptom control. Check compliance with stool softeners and lifestyle modification. Consider second-line therapy if inadequate response.

8–12 weeks

Decision point for fissure: if chronic fissure unresponsive to 8 weeks of topical therapy, refer to colorectal surgeon. Grade II–III haemorrhoids failing conservative management → specialist referral for banding or sclerotherapy.

3–6 months

Post-surgical follow-up: wound healing, recurrence assessment. Pelvic floor physiotherapy review for faecal incontinence. Reassess colonoscopy results and implement surveillance plans if polyps or malignancy identified.

12 months and beyond

Long-term surveillance: CRC surveillance colonoscopy per NHRMC/NBCSP guidelines. Annual review of continence management plan. Encourage ongoing fibre intake, adequate hydration, and regular bowel screening participation.

Special Populations

🤰 Pregnancy

Haemorrhoids: Extremely common in 2nd/3rd trimester due to progesterone-mediated venous dilation, increased intra-abdominal pressure, and constipation. Conservative management first-line (fibre, fluids, sitz baths). Avoid topical steroid preparations >7 days. Rubber band ligation is contraindicated in pregnancy.

Anal fissure: GTN 0.2% ointment — limited data in pregnancy but generally considered low risk for short courses; diltiazem 2% preferred by some practitioners. Sitz baths are safe and effective.

Perianal abscess: I&D is safe under local anaesthesia in pregnancy. Amoxicillin + clavulanate is safe; metronidazole traditionally avoided in 1st trimester (teratogenicity theoretical; Category B2). Clindamycin is an alternative.

Rectal bleeding: Always exclude placenta praevia (painless vaginal bleeding) and other obstetric causes before attributing to anorectal sources. Flexible sigmoidoscopy is considered safe in pregnancy; colonoscopy only if strongly indicated.

Avoid codeine and loperamide where possible (risk of neonatal respiratory depression, particularly in 3rd trimester and labour).

👶 Paediatrics

Anal fissure: The most common cause of rectal bleeding in infancy and childhood. Almost always associated with constipation. Treatment is dietary (fibre, fluids, fruit juice) plus stool softeners (macrogol 3350 is first-line in children >6 months).

Rectal prolapse: Self-limiting in >90% of children <3 years. Associated with constipation, diarrhoeal illness, cystic fibrosis (always screen), and malnutrition. Conservative management is first-line. Injection sclerotherapy or Thiersch suture for refractory cases.

Perianal abscess: More common in infants (males >females). May indicate underlying immunodeficiency if recurrent (e.g., leucocyte adhesion deficiency, chronic granulomatous disease). Simple I&D usually curative; antibiotics not required for most cases.

Haemorrhoids: Rare in children; always investigate for portal hypertension if present.

Always consider child abuse in the differential of perianal injury, bruising, or recurrent fissure in unusual locations. Refer to child protection services as per mandatory reporting obligations.

👴 Elderly (>65 years)

Rectal bleeding: Higher risk of serious pathology — diverticular bleeding, angiodysplasia, and CRC all increase with age. Lower threshold for colonoscopy referral.

Faecal incontinence: Prevalence up to 50% in residential aged care. Contributing factors include dementia, immobility, medications (laxatives, PPIs), faecal impaction with overflow, and reduced rectal compliance. Scheduled toileting programmes are effective.

Anticoagulants: Many elderly patients are on warfarin, DOACs (apixaban, rivaroxaban), or antiplatelets — these increase bleeding risk from any anorectal source. Check INR/anti-Xa levels before procedures. Do not stop anticoagulants without specialist advice for minor anorectal bleeding.

Surgical fitness: Rectal prolapse repair (perineal approaches — Delorme/Altemeier) preferred in frail elderly. Sacral nerve stimulation for faecal incontinence may be considered in selected patients.

Bowel cancer screening: NBCSP sends kits to ages 45–74. Encourage participation even beyond screening age if symptomatic. Polypharmacy review — assess for contributing medications.

🫘 Renal Impairment

Angiodysplasia: Higher prevalence in CKD patients (uraemic platelet dysfunction). Also exacerbated by anticoagulation during haemodialysis. Desmopressin (DDAVP) 0.3 μg IV may be used for acute bleeding episodes.

Constipation: Common due to phosphate binders (calcium carbonate, sevelamer), iron supplements, and reduced fluid intake. Macrogol 3350 is preferred (avoid magnesium-containing laxatives in CKD 4–5). Avoid sodium phosphate bowel preparations (risk of acute phosphate nephropathy).

Fistula-related sepsis: Dialysis patients with arteriovenous fistulas in the arm may have lower GI bleeding from vascular access-related complications. Consider this in the differential.

eGFR-based dose adjustments required for: amoxicillin + clavulanate (reduced doses in eGFR <30), metronidazole (accumulation of metabolites in severe renal impairment — reduce frequency). Ciprofloxacin requires dose reduction if eGFR <30.

🫁 Hepatic Impairment

Portal hypertensive colopathy: Patients with cirrhosis and portal hypertension may develop colonic angiodysplasia and haemorrhoids. Haemorrhoidal bleeding may be more severe due to coagulopathy and thrombocytopaenia. Avoid rectal procedures in decompensated cirrhosis without hepatologist input.

Coagulopathy: Deranged INR, low platelets, and reduced clotting factor synthesis increase bleeding risk. Correct coagulopathy before elective procedures. Vitamin K, FFP, or platelets as indicated.

Medications: Lactulose first-line for constipation in liver disease (also reduces hepatic encephalopathy risk). Avoid paracetamol doses >2 g/day in severe hepatic impairment. Metronidazole — use with caution (hepatotoxicity risk with prolonged use).

Refer to hepatologist if rectal bleeding is suspected to be related to portal hypertensive gastropathy or varices (upper GI source) rather than anorectal pathology.

🛡️ Immunocompromised

HIV/AIDS: Increased incidence of perianal abscess, fistula, condylomata, HSV ulcers, CMV colitis, and Kaposi sarcoma. Perianal disease may be the presenting feature of undiagnosed HIV. Low threshold for HIV testing in recurrent or atypical perianal sepsis.

Crohn's disease: Perianal fistula and abscess occur in 30–50% of Crohn's patients. Requires MRI pelvis, examination under anaesthesia (EUA), and multidisciplinary management (gastroenterologist + colorectal surgeon). Anti-TNF therapy (infliximab) is the mainstay of medical treatment for perianal Crohn's.

Transplant recipients / biologic therapy: Atypical infections, delayed wound healing, increased surgical risk. Conservative management where possible. Broad-spectrum antibiotics with Pseudomonas and fungal cover if severe sepsis.

CMV colitis should be considered in immunocompromised patients presenting with bloody diarrhoea. Faecal CMV PCR and colonoscopic biopsies are required for diagnosis. Ganciclovir or valganciclovir is the treatment of choice.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Aboriginal and Torres Strait Islander peoples experience a disproportionate burden of gastrointestinal disease, including higher rates of colorectal cancer (1.4 times the rate of non-Indigenous Australians), later-stage presentation, and significantly lower participation in the National Bowel Cancer Screening Program. Anorectal conditions such as haemorrhoids, fissures, and abscesses are also more prevalent in some communities, influenced by dietary factors (low fibre intake in remote communities with limited access to fresh produce), higher rates of chronic constipation, and delayed access to specialist care.

Screening participation

NBCSP participation rates for Aboriginal and Torres Strait Islander peoples remain approximately 25–30% lower than for non-Indigenous Australians. Culturally appropriate health promotion through Aboriginal Community Controlled Health Organisations (ACCHOs), Indigenous health workers, and community-led programs is essential to improve uptake.

Access to specialist care

Geographic isolation in remote and very remote communities (particularly in the Northern Territory, Western Australia, and Far North Queensland) means that access to colorectal surgeons, gastroenterologists, and endoscopy services is severely limited. Telehealth consultations and surgical outreach programs are critical. Median wait times for colonoscopy in remote areas may exceed 90 days compared with 30 days in metropolitan centres.

Diet and lifestyle factors

Many remote communities have limited access to affordable fresh fruit, vegetables, and high-fibre foods, contributing to chronic constipation and straining. The "Closing the Gap" nutrition initiatives and community store policies (e.g., Alice Springs "Good Food" program) aim to improve dietary quality but progress has been uneven.

Cultural and social considerations

Anorectal symptoms carry significant cultural shame and embarrassment in many Aboriginal and Torres Strait Islander communities, leading to delayed presentation. Same-sex healthcare providers may be preferred for sensitive examinations. Practitioners should use culturally safe communication, allow time for yarning, involve family and Elders where appropriate, and use interpreter services for patients whose primary language is not English (e.g., Yolŋu Matha, Kriol, Pitjantjatjara).

Chronic disease comorbidity

High rates of diabetes mellitus (3–4× higher than non-Indigenous Australians), chronic kidney disease, and obesity contribute to increased risk of surgical complications, impaired wound healing, and perianal sepsis. A holistic, multidisciplinary approach addressing comorbidities is essential. The RACGP's National Guide to a Preventive Health Assessment for Aboriginal and Torres Strait Islander People (3rd edition) provides comprehensive screening recommendations.

Community-level interventions

ACCHOs play a central role in bowel cancer awareness, FOBT kit distribution, and facilitating colonoscopy referrals. Integrated health promotion that links anorectal health with broader chronic disease management, sexual health, and men's/women's health programs is most effective. RHDAustralia provides guidelines relevant to perianal infections in settings where rheumatic heart disease and chronic streptococcal infections may complicate presentations.

✅

Practical recommendations for clinicians:

Proactively offer bowel cancer screening to all eligible Aboriginal and Torres Strait Islander patients aged 45–74, with culturally sensitive explanations of the iFOBT kit.
Use Aboriginal Health Practitioners and Indigenous health workers as intermediaries for discussing sensitive anorectal symptoms.
Prioritise same-day or expedited referral pathways for patients in remote communities who present with rectal bleeding, rather than watchful waiting that may result in loss to follow-up.
Ensure stool softeners and fibre supplements are available through community clinic pharmacies and remote area stores.
Advocate for improved endoscopy and surgical access through the Australian Government's Indigenous Australians Health Programme (IAHP).

Quick Reference — First-Line Management

Acute anal fissure

Fibre + sitz baths + GTN 0.2% or diltiazem 2% ointment

8 weeks

90% heal conservatively

Chronic anal fissure

Diltiazem 2% (preferred) ± botulinum toxin

8–12 weeks

Refer if no response — lateral sphincterotomy

Grade I–II haemorrhoids

Fibre + fluids + sitz baths ± Proctosedyl® 7 days

Ongoing

Rubber band ligation if Grade II persistent

Grade III–IV haemorrhoids

Surgical referral (haemorrhoidectomy / THD)

Variable

Grade IV = urgent surgical referral

Thrombosed external haemorrhoid

Excision under LA (<72 hrs) or conservative (>72 hrs)

Days

Paracetamol + ibuprofen for analgesia

Perianal abscess

Incision & drainage ± amoxicillin+clavulanate

5–7 days antibiotics if indicated

Antibiotics NOT needed if simple I&D, no cellulitis

Faecal incontinence

Pelvic floor physio + loperamide ± bowel programme

Ongoing

Endoanal USS + specialist referral if sphincter defect

Rectal bleeding + red flags

Urgent colonoscopy (<30 days)

As soon as possible

FBC, ferritin, iFOBT, calprotectin

📚 References

1. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of haemorrhoids. Dis Colon Rectum. 2018;61(3):284–292.
2. Cross KL, Massey EJ, Fowler AL, Monson JR. The management of anal fissure: ACPGBI position statement. Colorectal Dis. 2008;10 Suppl 3:1–7.
3. Garg P, Song J, Bhatia A, Kalia H, Menon GR. The efficacy of anal fistula plug in fistula-in-ano: A systematic review. Colorectal Dis. 2014;16(6):431–439.
4. Colorectal Surgical Society of Australia and New Zealand (CSSANZ). Clinical practice guidelines for the management of perianal abscess and fistula-in-ano. CSSANZ; 2021.
5. Australian Institute of Health and Welfare (AIHW). Cancer data in Australia. Canberra: AIHW; 2023. Available from: https://www.aihw.gov.au/reports/cancer/cancer-data-in-australia.
6. National Health and Medical Research Council (NHMRC). Clinical practice guidelines for the prevention, early detection and management of colorectal cancer. NHMRC; 2017 (updated 2024).
7. Royal Australian College of General Practitioners (RACGP). National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. 3rd ed. Melbourne: RACGP; 2018.
8. Bharucha AE, Dunivan G, Goode PS, et al. Epidemiology, pathophysiology, and classification of faecal incontinence: State of the science summary for the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK) workshop. Am J Gastroenterol. 2015;110(1):127–136.
9. Gallo G, Martellucci J, Sturiale A, et al. Consensus statement of the Italian Society of Colorectal Surgery (SICCR): management and treatment of pilonidal disease. Tech Coloproctol. 2021;25(5):551–562.
10. Emile SH, Elfeki H, Shalaby M, Sakr A, Sileri P. Perineal rectosigmoidectomy for rectal prolapse: A systematic review and meta-analysis. Int J Colorectal Dis. 2020;35(8):1419–1434.
11. Australian Government Department of Health and Aged Care. National Bowel Cancer Screening Program: Program information. Canberra: Commonwealth of Australia; 2024. Available from: https://www.health.gov.au/our-work/national-bowel-cancer-screening-program.
12. Continence Foundation of Australia. Guidelines for the management of faecal incontinence. Melbourne: Continence Foundation of Australia; 2022. Available from: https://www.continence.org.au.
13. Stewart DB, Gaertner WB, Glasgow SC, Migaly J, Feingold DL, Steele SR. Clinical practice guidelines for the management of pilonidal disease. Dis Colon Rectum. 2019;62(2):146–157.
14. Cotter TG, Gohil SM, Pardi DS. Solitary rectal ulcer syndrome: An update. Gastroenterol Hepatol. 2020;16(5):258–266.
15. Royal Australian and New Zealand College of Radiologists (RANZCR). Diagnostic imaging referral guidelines. 5th ed. Sydney: RANZCR; 2023.

for PBS scripts. Utilise ACCHS pharmacies and Remote Area Aboriginal Health Worker programs for medication supply in remote areas. Avoid initiating benzodiazepines; support holistic pain management including community-based exercise programs.

Preventive health

Promote bone health: encourage vitamin D supplementation (1000 IU daily in deficient individuals), smoking cessation support, reduction of alcohol intake, and weight-bearing exercise. MBS Item 715 health checks provide a structured opportunity to assess bone health, screen for osteoporosis risk factors, and discuss musculoskeletal health in a culturally safe context.

Quick Reference: Differential Diagnosis at a Glance

Costovertebral dysfunction

Paracetamol ± NSAID; manual therapy

2–6 weeks

Provocable on palpation; no red flags

Thoracic compression fracture

Paracetamol; ± calcitonin; DXA + osteoporosis Rx

6–12 weeks healing

Elderly; osteoporosis; acute onset

ACS (posterior MI)

Aspirin 300 mg, GTN, heparin; urgent PCI

Time-critical

ECG, troponin; CV risk factors

Aortic dissection

IV labetalol; urgent CT aortogram; surgery (Type A)

Time-critical

Tearing pain; BP differential >20 mmHg

Vertebral osteomyelitis

IV antibiotics (vancomycin + ceftriaxone initially); ID consult

6 weeks IV antibiotics

Fever, elevated CRP, IV drug use

Biliary colic / cholecystitis

Paracetamol ± morphine; lap cholecystectomy

Surgical within 72 h (cholecystitis)

RUQ/infrascapular; post-prandial; RUQ US

📚 References

1. Briggs AM, Smith AJ, Straker LM, Bragge P. Thoracic spine pain in the general population: prevalence, incidence and associated factors in children, adolescents and adults. A systematic review. BMC Musculoskelet Disord. 2009;10:77.
2. National Health and Medical Research Council (NHMRC). Evidence-based management of acute musculoskeletal pain. Canberra: NHMRC; 2003 (updated 2020).
3. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Summary report 2023. Canberra: AIHW; 2023.
4. Deyo RA, Rainville J, Kent DL. What can the history and physical examination tell us about low back pain? JAMA. 1992;268(6):760–765.
5. Stochkendahl MJ, Kjaer P, Hartvigsen J, et al. National Clinical Guidelines for non-surgical treatment of patients with recent onset low back pain or lumbar radiculopathy. Europ Spine J. 2018;27(1):60–75.
6. Erwin WM, Jackson PC, Homonko DA. Innervation of the human costovertebral joint: implications for clinical back pain syndromes. J Manipulative Physiol Ther. 2000;23(6):395–403.
7. Royal Australian College of General Practitioners (RACGP). Guidelines for preventive activities in general practice. 9th edn. Melbourne: RACGP; 2018 (updated 2023).
8. Hirsch JA, Singh V, Falco FJE, et al. Thoracic facet joint interventions. Pain Physician. 2016;19(4):E581–E593.
9. Erwin WM, Jackson PC. The costovertebral joint: anatomy, biomechanics, and clinical significance in thoracic back pain syndromes. J Can Chiropr Assoc. 2003;47(2):112–120.
10. Strayer RJ, Gunnerson JM, Brown LH, et al. Aortic dissection: clinical features, diagnosis, and management. Aust Crit Care. 2019;32(2):144–153.
11. Ombregt L. A system of orthopaedic medicine. 3rd edn. Edinburgh: Churchill Livingstone Elsevier; 2013. Chapter 18: Thoracic spine.
12. Lin CC, Chen KH, Li DM, et al. Characteristics and outcomes of patients presenting with thoracic back pain to the emergency department. Emerg Med Australas. 2020;32(5):805–811.

for PBS-listed medicines at participating pharmacies.

Cultural safety

Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.

Medication adherence

Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.

Specific conditions

Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3–4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.

Referral pathways

Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).

for PBS-listed medicines at participating pharmacies.

Cultural safety

Medication adherence

Specific conditions

Referral pathways

📚 References

1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924–939.
3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736–745.
4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583–1599.
5. Smolen JS, Landewé RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3–18.
6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487–1498.
10. Pisetsky DS. Antinuclear antibody testing — misunderstood or misused? Clin Immunol. 2023;255:109717.
11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Association–European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771–1782.
12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFα blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155–158.
13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).