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Anorectal Disorders


Hemorrhoids are dilated veins located beneath the lining of the anal canal. Internal hemorrhoids are located in the upper anal canal. External hemorrhoids are located in the lower anus.

Internal hemorrhoids become symptomatic when constipation causes disruption of the supporting tissues and resultant prolapse of the dilated anal veins. The most common symptom of internal hemorrhoids is painless rectal bleeding, which is usually bright red and ranges from a few drops to a spattering stream at the end of defecation. If internal hemorrhoids remain prolapsed, a dull aching may occur. Blood and mucus stains may appear on underwear, and itching in the perianal region.

Management of internal hemorrhoids

Grade 1 and uncomplicated grade 2 hemorrhoids are treated with avoidance of nonsteroidal anti-inflammatory drugs.

Symptomatic grade 2 and grade 3 hemorrhoids. Treatment consists of hemorrhoid banding with an anoscope.

Grade 4 hemorrhoids require surgical hemorrhoidectomy.

External Hemorrhoids

External hemorrhoids occur most often in young and middle-aged adults, becoming symptomatic only when they become thrombosed.

External hemorrhoids are characterized by rapid onset of constant burning or throbbing pain, accompanying a new rectal lump.

Anal Fissures

An anal fissure is a longitudinal tear in the distal anal canal, usually in the posterior or anterior midline. Anal fissures may be associated with secondary changes such as a sentinel tag, hypertrophied anal papilla, induration of the edge of the fissure, and anal stenosis. A patient with multiple fissures, or whose fissure is not in the midline, is more likely to have Crohn's disease.


High fiber foods, warm sitz baths, stool softeners (if necessary), and daily application of 1% hydrocortisone cream to the fissure.

Lateral partial internal sphincterotomy is indicated when 4 weeks of medical therapy fails. It consists of surgical division.

Levator ani syndrome and proctalgia fugax

Levator ani syndrome refers to chronic or recurrent rectal pain, with episodes lasting 20 minutes or longer. Proctalgia fugax.

Levator ani syndrome and proctalgia fugax are more common in patients under age 45, and psychological factors are not always

Levator Ani Syndrome is caused by chronic tension of the levator muscle. Proctalgia fugax is caused by rectal muscle spasm. Proctalgia fugax and levator ani syndrome have not been found to be of psychosomatic origin, although stressful events may trigger attacks.

Diagnosis and clinical features

Levator ani syndrome is characterized by a vague, indefinite rectal discomfort or pain. The pain is felt high in the rectum.


Levator ani syndrome. Treatment with hot baths, nonsteroidal anti-inflammatory drugs, muscle relaxants, or levator muscle.

Proctalgia Fugax. For patients with frequent attacks, physical modalities such as hot packs or direct anal pressure with a finger.

Pruritus Ani

Pruritus ani is characterized by the intense desire to scratch the skin around the anal orifice. It occurs in 1% of the population. Pruritus ani may be related to fecal leakage.

Patients report an escalating pattern of itching and scratching in the perianal region. These symptoms may be worse at night.

Perianal Abscess

The anal glands, located in the base of the anal crypts at the level of the dentate line, are the most common source of perianal infection. Acute infection presents as an abscess, and chronic infection results in a fistula.

The most common symptoms of perianal abscess are swelling and pain. Fevers and chills may occur. Perianal abscess is common.

Management of perianal abscess. Perianal abscesses are treated with incision and drainage.