Anal and perianal disorders are some of the most common yet distressing conditions affecting people of all ages. While many are benign, they can significantly impact quality of life due to symptoms like bleeding, pain, itching, and discharge. Understanding these conditions is essential for early diagnosis and effective management.
This guide covers everything from hemorrhoids and anal fissures to rectal prolapse, fistulas, and perianal abscesses, with their causes, signs, differential diagnoses, and treatments — all based on clinical insights and visual references.
Common Symptoms and Differential Diagnosis
Key Symptoms:
- Rectal bleeding: Bright red blood per rectum, staining toilet or paper
- Anal lump: Internal or external swelling
- Anal discharge: Mucous or pus from the anus
- Pain or discomfort
- Itching (pruritus ani)
Differential Diagnoses:
| Symptom | Common Causes |
|---|---|
| Blood per rectum | Hemorrhoids, fissures, polyps, colorectal cancer, angiodysplasia, diverticulosis |
| Anal lump | Hemorrhoids, perianal hematoma, skin tags, warts, rectal prolapse |
| Anal discharge | Proctitis, infections, fistulas, hemorrhoids |
| Pain | Anal fissures, thrombosed hemorrhoids, abscess, proctalgia fugax |
| Itching | Idiopathic, eczema, candidiasis, worms, psoriasis, warts |
Hemorrhoids (Piles)
Definition
Hemorrhoids are dilated venous plexuses in the anal canal, occurring above (internal) or below (external) the dentate line.
Causes:
- Straining (low-fiber diet, constipation)
- Pregnancy
- Prolonged sitting
- Portal hypertension
Symptoms:
- Bright red bleeding
- Pain (especially in external thrombosis)
- Prolapse
- Anal itching
Classification:
| Degree | Description |
|---|---|
| First | Bulge into lumen, no prolapse |
| Second | Prolapse during defecation, spontaneous reduction |
| Third | Manual reduction required |
| Fourth | Irreducible and possibly strangulated |
Treatment:
- 1st degree: Dietary fiber, fluids, bulk-forming laxatives
- 2nd/3rd degree: Rubber band ligation, cryotherapy, sclerotherapy
- 4th degree: Hemorrhoidectomy (open/closed/stapled), HALO procedure
Anal Fissure
Definition:
A linear tear in the anal canal mucosa, most commonly posterior midline (90%).
Causes:
- Passage of hard stool
- Anal trauma (childbirth, instrumentation)
- Crohn’s disease
- STIs or carcinoma (rare)
Symptoms:
- Severe pain during defecation
- Bright red bleeding
- Sentinel pile (skin tag)
- Spasm of internal anal sphincter
Treatment:
- 1st-line: Stool softeners, topical nitroglycerine or calcium channel blockers
- 2nd-line: Botox injection, lateral sphincterotomy (95% cure rate)
- Investigate for atypical fissures with biopsy if needed
Perianal Hematoma
Definition:
A ruptured perianal vein, causing a painful lump due to blood accumulation.
Causes:
- Sudden straining or lifting
- Trauma
Symptoms:
- Acute onset pain
- Tender, dark purple swelling
Treatment:
- Small: Conservative
- Large: Evacuation of clot for immediate relief
Perianal Abscess
Definition:
A localized collection of pus near the anus due to cryptoglandular infection.
Types:
- Perianal (near anal margin)
- Ischiorectal (into ischiorectal fossa)
- Intersphincteric
- Supralevator
Symptoms:
- Severe pain, redness, swelling
- Fever, malaise, tenderness
Treatment:
- Incision and drainage
- Antibiotics (if systemic symptoms)
Fistula-in-Ano
Definition:
An abnormal track between the anal canal and perianal skin, often after an abscess.
Causes:
- Cryptoglandular infection
- Crohn’s disease
- Tuberculosis
Classification:
- Low (below sphincter)
- High (above sphincter)
Symptoms:
- Persistent discharge
- Pain, itching
- Recurrent abscesses
Treatment:
- Fistulotomy (track laid open)
- Seton placement
- Flap procedures for complex/high fistulas
Rectal Prolapse
Definition:
Protrusion of the rectal mucosa or full thickness of the rectum through the anus.
Causes:
- Constipation
- Straining
- Pelvic floor weakness (esp. elderly women)
- Neurologic disease
Symptoms:
- Visible mass
- Fecal incontinence
- Tenesmus, discomfort
- Mucosal discharge
Treatment:
Manual reduction (initially)Surgery:
- Delorme’s procedure
- Laparoscopic rectopexy
- Sigmoid resection ± rectopexy
Proctalgia Fugax
Definition:
Sudden, severe spasmodic rectal pain without a known structural cause.
Features:
- No visible lesion
- Episodic, often at night
- Self-limiting
Treatment:
- Reassurance
- Warm baths
- Anxiolytics or muscle relaxants in severe cases
Pilonidal Sinus
Definition:
A blind-ending track containing hair in the natal cleft.
Causes:
- Friction, trauma, or congenital tract
- Hair penetration in sacral region
- Occupation-related (drivers, barbers)
Symptoms:
- Pain, swelling, discharge in the natal cleft
- Visible sinus or opening
- Itching or discomfort when sitting
Treatment:
- Hair removal, hygiene
- Sinus excision + primary or flap closure
- Laser therapy for recurrent cases
Itching (Pruritus Ani)
Causes:
- Idiopathic (50%)
- Dermatologic (eczema, psoriasis)
- Infectious (worms, candida, STIs)
- Inflammatory (Crohn’s, hemorrhoids, proctitis)
Treatment:
- Identify and treat underlying cause
- Maintain hygiene
- Avoid irritants (perfumed soaps)
- Antihistamines/topical steroids for relief
Summary Table of Common Benign Anal Disorders
| Disorder | Main Symptoms | Treatment Approach |
|---|---|---|
| Hemorrhoids | Bleeding, lump, itching, prolapse | Diet, rubber band ligation, surgery |
| Anal Fissure | Severe pain, bleeding | Laxatives, topical creams, surgery |
| Perianal Abscess | Swelling, pain, fever | Incision & drainage |
| Fistula-in-ano | Discharge, external opening | Fistulotomy, seton |
| Rectal Prolapse | Mass, incontinence | Rectopexy, resection |
| Proctalgia Fugax | Sudden rectal pain | Reassurance, warm baths |
| Pilonidal Sinus | Midline sinus, pain, discharge | Excision, hair removal |
FAQs
Q1. Are hemorrhoids and fissures the same?
No. Hemorrhoids are swollen veins; fissures are tears in the anal lining.
Q2. Can you get rid of piles without surgery?
Yes. Mild to moderate cases often respond to dietary changes and non-invasive therapies.
Q3. What does an anal fistula feel like?
You may notice a painful lump, pus discharge, or recurrent abscess.
Q4. Is anal itching always due to hygiene?
No. It can be caused by infections, skin diseases, or systemic conditions.
Q5. Is rectal prolapse life-threatening?
Not immediately, but it requires evaluation and surgical correction if persistent.
