Anal Surgical Conditions

Medically reviewed by: Gary H. Hoffman, MD

Perianal pain (pain of the skin surrounding the anus), and anal pain is a common patient complaint. The pain may be severe because the anus and surrounding skin are heavily endowed with nerve endings. While the pain often feels severe, the cause is generally not a serious one and can be treated by your doctor with outpatient therapy or procedures.

Causes of perianal or perirectal pain include:

  • Anal fissure
  • An abscess (perirectal or perianal abscess)
  • Anorectal fistula
  • Thrombosed hemorrhoid
  • Infections
  • A rare anal cancer or rectal cancer

Treatment options vary based upon the particular cause of the pain. Consultation with your physician will help to determine the underlying cause of the pain.

Abscess Drainage

Anal abscesses are generally caused by the bacterial invasion of mucus-secreting glands within the anus or rectum. These glands become inflamed and unable to drain adequately, resulting in a collection of pus that spreads outward. People with Crohn’s disease, diabetes, HIV and AIDS are at a higher risk for developing anal abscesses. However, most patients do not have a predisposing cause for the abscess.  Symptoms of an anal abscess include:

  • A detectable painful lump in the anal region
  • Painful bowel movements
  • Lower abdominal pain
  • Swelling in anal area or buttocks
  • Drainage of pus from a pimple on the buttocks
  • Systemic signs such as fever or malaise

There are several places within the anal and rectal regions that abscesses form. A perirectal abscess is a pus-filled cavity that begins in the rectum and extends into the deep tissues in the buttocks surrounding the anus. A perianal abscess is a collection of pus that forms much shallower within the tissues surrounding the anus.

An abscess may look similar to an infected pimple, but is a much more serious issue requiring immediate attention. Complications resulting from anorectal abscesses often can be minimized with immediate attention and treatment.  Watchful waiting usually is not a good idea.

Drainage of a perianal or a perirectal abscess is often performed as an outpatient procedure by your physician. This involves making an incision over the abscess so that pus can drain freely and the area can heal.  Most patients feel relief once the abscess is drained.


Following abscess drainage, about one half of patients do not heal and a fistula forms.  A fistula is an abnormal connection between the anus or rectum and the skin of the buttocks.  Often, the fistula burrows through the anal sphincter.  The reason that some patients develop a fistula after treatment is unknown. Some fistulas arise spontaneously in individuals with Crohn’s disease, tuberculosis, cancer or anal or rectal injuries.

Your doctor will be able to diagnose a fistula by simple observation or by looking through an anoscope that is inserted into the rectum. The most common form of treatment for an anorectal fistula is surgical and is called a fistulotomy.

Performed under intravenous and local anesthesia, usually in the outpatient setting of a surgical center or hospital, the surgeon opens the fistula and coverts the closed fistula tunnel to an open groove which heals over the next few days to weeks.  A small portion of the anal sphincter may need to be cut.

Although safe, a fistulotomy may be associated with a small incidence of temporary or permanent incontinence.  Incontinence causes difficulty in controlling stool or gas.  In practice, this is a rare occurrence and is usually the result of cutting a small portion of the muscle in an attempt to cure the disease.  Sometimes, rather than cutting this small amount of muscle, the surgeon places a seton.  A seton looks like a rubber band and is used to treat the fistula over a longer period of time if a large amount of muscle is involved with the fistula.

Sometimes the muscle has already been damaged by the pus and the extent of the disease.  An experienced surgeon will help you to understand your options and the nature of the procedures available for treatment.

Fissure Treatment

An anal fissure is a small tear or ulcer in the lining of the anus.  The tear may extend into the anal canal. Symptoms of anal fissures include pain and bleeding, most often during bowel movements.  Fissures are often difficult to treat by medical means.

Fissures are typically caused by trauma or sudden increased stretching of the anus.  The trauma can be due to a hard bowel movement, or diarrhea. Women often develop anal fissures during childbirth.

There are several forms of treatment for anal fissures. Non-surgical options include stool softeners and warm sitz baths for ten minutes following a bowel movement. Other forms of treatment include topical steroid ointments, topically placed smooth muscle relaxants, topical anesthetics or lubricant suppositories. Rarely an injection of Botox® may cure the fissure.  In many cases, an operation is required. The most common operation is called a lateral internal sphincterotomy.  A sphincterotomy involves the surgical cutting of a small portion of the internal anal sphincter.  This is performed as an outpatient procedure under intravenous sedation and local anesthesia.  As in a fistulotomy, there is a low incidence of temporary or permanent mild postoperative incontinence.  Although rare, there may be a recurrence of the fissure, necessitating further evaluation and retreatment.  Any concerns should be discussed with your physician.

Thrombotic Hemorrhoid Treatment

A thrombotic hemorrhoid is diagnosed when hemorrhoids become engorged with blood and then the blood clots.

Sometimes your physician may recommend home treatments such as pain medication, sitz baths, stool softeners and ointments.

Early treatment is helpful to relieve pain and begin the healing period. Often, your doctor may be able to remove the blood clot and decrease the pain by making a small incision over the thrombotic hemorrhoid and evacuating the clot.

If you are experiencing anal pain or discomfort of any sort, it is important to schedule an appointment to see your physician.

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