From Clinic to Recovery · First Edition
Chapter 07 — Common Anal Conditions: Hemorrhoids, Anal Fissure, and Perianal Abscess and Fistula
Dr. Tamer Rushdy Elalfy · 20 min read
In this chapter
Anal conditions are among the most common reasons for a surgical clinic visit, and among the hardest for patients to talk about. Many arrive after months of embarrassment, self-treatment, or advice from family, and some fear that every bleed or lump is cancer. The three conditions in this chapter differ in cause and treatment, but the counseling shares the same foundations: privacy and dignity during the examination, a clear explanation of what is wrong, honest discussion of a stepped treatment plan, and practical advice on bowel habits, pain, and wound care.
Learning objectives After reading this chapter you should be able to:
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Table 7.1. Common anal conditions at a glance.
| Condition | First step | Procedure if needed | Consent priority |
|---|---|---|---|
| Hemorrhoids | Fiber, fluids, short and unstrained toilet visits | Office banding; surgery for grade 4 or failed banding | Pain and bleeding after banding or surgery |
| Anal fissure | Fiber, softeners, warm-water baths, then relaxing ointment | Botulinum toxin; lateral internal sphincterotomy | Small risk of reduced control of gas or stool |
| Abscess and fistula | Prompt drainage of an abscess | Fistulotomy, or seton then a sphincter-sparing repair | Recurrence balanced against continence |
STEP 1 Explaining the conditions and the treatments
7.1 The consultation for anal symptoms
Begin by acknowledging that the subject is difficult to discuss, and give the patient time to describe the symptoms in their own words: bleeding, pain, a lump, itching, discharge, or a change in bowel habit. Ask about stool consistency, straining, time spent on the toilet, and how long the problem has lasted. Explain the examination before it starts, offer a chaperone to every patient, and respect a request for an examiner of the same sex where it can be met. Keep the patient covered except for the area being examined.
Script: explaining the examination “I need to look at the area and gently examine inside with a gloved finger, and with a small viewing tube if it is comfortable. It takes a few minutes. You will lie on your left side with your knees bent, and you will be covered. A nurse will be with us. If anything hurts, tell me and I will stop.” |
Bleeding should not be attributed to hemorrhoids without an examination. Hemorrhoids are common and often coexist with other conditions, and bleeding from a bowel cancer can be mistaken for hemorrhoids. Anoscopy is advised for new patients whenever possible, and colonoscopy is arranged when the history or age suggests another cause, such as a change in bowel habit, anemia, weight loss, a family history of bowel cancer, or an age at which screening is due [1, 2].
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 7.1. Stepped treatment of the three common anal conditions.
7.2 Hemorrhoids
Dietary and lifestyle measures are the first treatment for symptomatic hemorrhoids: more fiber, enough fluid, and less straining and time on the toilet [2]. Topical preparations can relieve symptoms, but the evidence for them is limited, and steroid creams should not be used for more than two weeks [2]. When symptoms continue, rubber band ligation is the most effective office treatment for grade 1 to 3 internal hemorrhoids and is well tolerated; excisional hemorrhoidectomy is more effective but more painful, with more complications, and is reserved for grade 4 hemorrhoids, combined internal and external disease, or failure of office treatment [1]. Doppler-guided hemorrhoidal artery ligation causes less pain than excision and is an option for internal hemorrhoids [1].
Script: explaining hemorrhoids and banding What they are. “Everyone has soft cushions of blood vessels inside the back passage. They help control wind and stool. When they swell or slip down, usually from straining or hard stools, we call them piles, or hemorrhoids. They can bleed, itch, or come out.” The first step. “The most important treatment is soft, easy stools: more fiber and water, and not sitting or straining on the toilet for long. That alone helps many people.” Banding. “If they still trouble you, we can place a small rubber band on each pile in the clinic. It takes a few minutes and needs no anesthetic. The pile shrinks and falls off with the band within about a week. You may feel a dull ache for a day or two, and notice a little blood when it falls off.” Surgery. “If the piles are large and stay outside, or banding has not worked, an operation removes them. It works well, but the first week or two are painful, so we plan pain relief carefully.” |
Hemorrhoids are common in pregnancy and are usually treated conservatively, with banding considered after delivery if symptoms persist [2]. In patients with cirrhosis, rectal varices must be distinguished from hemorrhoids before any procedure [2]. A thrombosed external hemorrhoid usually settles over 1 to 2 weeks; selected patients seen early with severe pain benefit from excision [1].
7.3 Anal fissure
An anal fissure is a tear in the lining of the anal canal, usually at the back, caused by passing a hard stool. The pain causes spasm of the internal sphincter, which reduces blood flow and stops the tear from healing. Acute fissures often heal with fiber, stool softeners, and warm-water baths. For chronic fissures, topical calcium channel blockers and topical nitrates each heal about half; calcium channel blockers cause fewer side effects, especially headache, and can be used first [3]. Botulinum toxin injection is about as effective as topical therapy and causes temporary leakage in about 5 in 100 patients [3]. Lateral internal sphincterotomy is the most effective treatment, healing at least 88 in 100 fissures, with a small risk of reduced control, which is lower when the division is limited to the length of the fissure [3].
Caution: fissures and medicines Topical nitrates can cause headache and low blood pressure, and must not be combined with medicines for erectile dysfunction such as sildenafil or tadalafil [3]. Ask every man about these medicines before prescribing. A fissure that is not in the midline, is painless, or does not heal needs examination under anesthesia to exclude Crohn’s disease, infection, or cancer. |
Script: explaining a fissure “You have a small tear in the skin at the opening of the back passage. Each time you open your bowels it stretches, which is why it is so painful, and the muscle around it tightens in spasm. That spasm slows healing. We will soften your stools and use an ointment that relaxes the muscle, for 6 to 8 weeks. Most fissures heal this way. If it does not, there are injection and surgical options, which we will discuss if needed.” |
7.4 Perianal abscess and fistula
An anal abscess is a collection of pus, usually starting in a small gland inside the anal canal. It is treated promptly by incision and drainage; antibiotics are reserved for patients with surrounding cellulitis, signs of systemic infection, or reduced immunity, and are not an alternative to drainage [4]. After drainage, about a third to a half of patients develop a fistula, a small tunnel between the inside of the anal canal and the skin, which keeps discharging or causes repeated abscesses [4].
A simple fistula that crosses little of the sphincter muscle can be treated by opening the tract (fistulotomy), which has a high success rate. When the tract crosses more muscle, cutting it would risk continence, so a soft thread (seton) is placed to keep it draining, and a sphincter-sparing repair, such as an advancement flap or ligation of the tract, is planned later [4]. Recurrent or complex fistulas raise the possibility of Crohn’s disease.
Script: explaining a fistula and seton “The abscess has left a small tunnel from inside the back passage to the skin. The muscles that control your bowels lie around it. If the tunnel crosses only a little muscle, we can open it and let it heal from the bottom up. If it crosses more, cutting it could weaken your control, so we place a soft thread through it to keep it draining and free of infection. Later we close the tunnel with an operation that protects the muscle. It may take more than one step, but protecting your control matters more than speed.” |
STEP 2 Preparation, medicines, and recovery
7.5 Before the procedure
- Bowels. Start fiber and plenty of fluid before any procedure, and treat constipation. Some units give a small enema before surgery.
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Blood thinners. Banding and surgery can bleed, especially when the band falls off. Plan anticoagulant and antiplatelet medicines individually (Chapter 22).
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Anesthesia. Banding needs no anesthetic. Surgery is done under general, spinal, or local anesthesia, usually as a day case.
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Medicines for erectile dysfunction. Record them before prescribing nitrate ointment.
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Privacy and timing. Many patients prefer to avoid the days before family events or travel. Agree a date that allows a quiet first week after surgery.
7.6 After the procedure
Pain after hemorrhoidectomy and fistula surgery is greatest during bowel movements in the first 7 to 10 days. Prepare the patient with a plan: regular paracetamol, an anti-inflammatory medicine if suitable, short courses of stronger medicine only if needed, and a stool softener from the first day, because opioids cause constipation and a hard stool is the most painful event of recovery. Warm-water baths or washing after each bowel movement soothe the area and keep wounds clean; patients who use water for washing after the toilet can continue to do so gently. Difficulty passing urine is more common after anal surgery and is the most frequent reason for an unplanned stay.
Open wounds after abscess drainage or fistulotomy heal from the base over several weeks. Explain that discharge and slight bleeding on the pad are expected, and that packing, if used, is changed by a nurse or reduced over time. A seton is left in place, may discharge a little, and should not be pulled.
7.7 Recovery
Table 7.2 and Figure 7.2 give typical times. Returning to normal activity is limited mainly by pain on sitting and during bowel movements, not by the risk of damaging the repair.
Table 7.2. Typical recovery after anal procedures.
| Activity | Banding | Hemorrhoidectomy or fistula surgery | Fissure treatment |
|---|---|---|---|
| Office work | The next day | About 1 to 2 weeks | Ointment: no time off; sphincterotomy: a few days |
| Driving | The next day | When sitting is comfortable and not taking strong pain medicine, often 1 week | A few days |
| Heavy work, sport | After a few days | About 2 to 4 weeks | About 1 to 2 weeks after sphincterotomy |
| Swimming | After a few days | When the wound has healed | After a few days |
| Sexual activity | When comfortable; avoid anal sex until healed | When comfortable; avoid anal sex until healed | Avoid anal sex until the fissure has healed |
| Prayer | Unchanged | Use a soft cushion when sitting; bowing and prostration as comfort allows | Unchanged; a cushion helps |
| Ramadan fasting | Unchanged | Wait until bowels are regular and comfortable; fasting raises the risk of hard stools | Drink well between iftar and suhoor and keep stools soft |
| Flying | Unchanged | After about 1 week; a cushion helps on long flights | Unchanged |
[Figure — diagram omitted in this text edition; see the figure caption below and the Word chapter file for the image]
Figure 7.2. Typical healing times after anal procedures, for use with patients.
STEP 3 Questions patients ask
“Is the bleeding cancer?”
Most bleeding from the back passage comes from hemorrhoids or a fissure, but we never assume that. I will examine you, and if your age or symptoms suggest it, we will look at the whole bowel with a camera test [1].
“Will the piles come back after banding?”
They can, especially if constipation and straining continue. Banding can be repeated. Soft stools and short toilet visits are the best protection [2].
“Which creams should I use?”
Creams may ease symptoms but do not cure piles. Do not use steroid creams for more than two weeks, because they thin the skin [2].
“Why is the operation so painful?”
The skin around the anus has many nerves. The pain is worst when opening the bowels in the first week to ten days. Soft stools, regular pain relief, and warm-water baths make a large difference.
“Will I lose control of my bowels?”
For most people, no. Fissure surgery carries a small risk of reduced control, mainly of wind; for fistulas, we choose an operation that protects the muscle. We will discuss your own risk before any operation [3, 4].
“The ointment gives me a headache. What can I do?”
Headache is common with nitrate ointment and often eases after the first days. Using less, or switching to a different ointment, usually helps [3].
“Why can’t you just give me antibiotics for the abscess?”
Antibiotics cannot reach pus that is trapped. The abscess must be opened and drained; antibiotics are added only in some cases [4].
“Why do I need a thread (seton) instead of a cure now?”
Because the tunnel passes through the muscle that controls your bowels. The thread keeps it draining safely while we plan an operation that protects that muscle.
“Can I wash with water after the toilet?”
Yes. Gentle washing with warm water is better than rubbing with paper, and it helps healing. Pat the area dry.
“Can I fast in Ramadan with this condition?”
Fasting can make stools harder. Drink plenty of water between iftar and suhoor, eat fiber, and take your softener. After surgery, wait until your bowels are comfortable before fasting.
“I am pregnant and have piles. What can I do?”
Piles are very common in pregnancy and usually improve after delivery. Fiber, fluids, and gentle creams are safe; procedures are usually delayed until after the baby is born [2].
STEP 4 Risks, warning signs, and consent
7.8 Material risks
Table 7.3 lists the risks of each procedure in the bands of Section 1.5. Replace figures marked “unit data” with your own audit figures.
Table 7.3. Material risks of anal procedures. Square brackets mark figures to replace with unit data.
| Procedure | Band | Outcome or risk, with typical frequency |
|---|---|---|
| Rubber band ligation | Common | Dull ache or pressure for 1 to 2 days; slight bleeding when the band falls off at 5 to 10 days |
| Less common | Heavier bleeding needing review; recurrence needing repeat banding [unit data] | |
| Rare but serious | Severe pain, fever, or difficulty passing urine after banding, which may signal pelvic infection and needs urgent assessment [unit data] | |
| Hemorrhoidectomy | Common | Significant pain for 1 to 2 weeks; discharge and spotting while the wounds heal |
| Less common | Difficulty passing urine; bleeding after the first week needing return to hospital [unit data] | |
| Rare but serious | Narrowing of the anus; reduced control of gas or stool; heavy bleeding needing reoperation [unit data] | |
| Fissure ointment or botulinum toxin | Common | Headache with nitrate ointment; recurrence after healing |
| Less common | Temporary leakage after botulinum toxin, about 5 in 100 [3] | |
| Lateral internal sphincterotomy | Common | Healing in at least 88 in 100 [3] |
| Less common | Reduced control of gas, or occasionally stool, usually mild [unit data] | |
| Abscess drainage | Common | A fistula later, in about a third to a half of patients [4]; a further abscess |
| Fistula surgery | Less common | Recurrence, higher after sphincter-sparing repairs [unit data] |
| Rare but serious | Reduced control of gas or stool, depending on how much muscle is involved [unit data] |
7.9 Consent checklist
Before the procedure ☐ Examination done with a chaperone; other causes of bleeding considered and investigated where indicated. ☐ Conservative measures tried and explained, including fiber, fluids, and toilet habits. ☐ Options discussed for the condition, including the next step if this one fails. ☐ Risks from Table 7.3 discussed, including continence where relevant, with unit figures where available. ☐ Existing control of gas and stool asked about and recorded, especially after childbirth or previous anal surgery. ☐ Blood thinners and medicines for erectile dysfunction recorded. ☐ Who will perform the procedure, including trainee involvement under supervision. ☐ Pain, stool-softener, and washing plan given; teach-back done; patient guide given in the patient’s language. |
7.10 Warning signs
Table 7.4. Green, amber, and red warning signs after anal procedures.
| Level | Signs after an anal procedure | What to do |
|---|---|---|
| Green | Pain on opening the bowels that eases day by day Spotting of blood or discharge on the pad Swelling of the skin around the anus Discharge from a seton | Expected. Follow the guide: soft stools, pain relief, and warm-water washing. |
| Amber | No bowel movement for 3 days despite softeners Temperature of 38 °C or more Increasing pain, redness, or swelling after the first few days Passing urine with difficulty | Call the clinic or contact number the same day. |
| Red | Heavy bleeding, with clots, or bleeding that does not stop Not able to pass urine at all Severe pain with fever or shivering, especially after banding Feeling faint or very unwell | Go to the emergency department or call an ambulance now. Bring this guide. |
Key points
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STEP 5 Patient education guide
The following pages may be photocopied and given to patients. Tick the treatment the patient had, and add your unit’s name, phone numbers, and review date before use.
PATIENT GUIDE Treatment for Piles, Fissure, or Anal Abscess and Fistula For you and your family. Keep it during your recovery. |
The treatment you had
☐ Banding of piles (hemorrhoids)
☐ Operation to remove piles (hemorrhoidectomy)
☐ Ointment or injection for a fissure
☐ Operation for a fissure (sphincterotomy)
☐ Drainage of an abscess
☐ Operation for a fistula, or a seton (soft thread) placed
Your most important job: soft, easy stools
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Eat fiber every day: vegetables, fruit, whole grains, beans, or a fiber supplement.
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Drink plenty of water, about 8 glasses a day unless we told you otherwise.
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Take the stool softener we gave you every day while you take strong pain medicine.
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Go when you feel the urge. Do not strain, and do not sit on the toilet for more than a few minutes. Leave your phone outside.
1. Pain and pain medicines
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The area will be sore, most of all when you open your bowels. This gets better day by day.
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Take your pain medicines regularly at first, as we told you.
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Sit in a shallow bath of warm water for 10 to 15 minutes, 2 or 3 times a day and after bowel movements. It eases pain and spasm.
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Strong pain medicines cause constipation. Keep taking your softener.
2. Wound care and washing
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Wash gently with warm water after each bowel movement and pat dry. Do not rub.
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Some blood and discharge on your underwear is normal for a few weeks. Wear a pad.
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If you have a seton, it may leak a little. Do not pull it. Keep the area clean.
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Open wounds heal from the bottom up. This takes a few weeks.
3. Eating and drinking
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Eat normally, with plenty of fiber and water.
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In Ramadan, drink plenty of water between iftar and suhoor and keep taking fiber. After an operation, ask us before fasting.
4. Rest, sitting, and clothes
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Rest for the first few days, but walk around the house.
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A soft cushion helps when sitting, praying, or travelling.
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Wear loose cotton underwear.
5. Getting back to normal
These are usual times. Your own plan is on your card.
| Activity | After banding | After an operation |
|---|---|---|
| Work or school | The next day | About 1 to 2 weeks |
| Driving | The next day | When sitting is comfortable and you are not taking strong pain medicine |
| Sport and heavy lifting | After a few days | About 2 to 4 weeks |
| Swimming | After a few days | When the wound has healed |
| Prayer | As usual | As usual, with a cushion. Bow and prostrate as comfort allows. |
| Sex | When comfortable | When comfortable. No anal sex until fully healed. |
6. Follow-up and results
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Your follow-up appointment or phone call is on your card.
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If tissue was sent to the laboratory, we will tell you the result.
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For a fissure: use the ointment for the full 6 to 8 weeks, even when the pain improves.
7. Warning signs: when to get help
| Level | What you notice | What to do |
|---|---|---|
| GREEN | Pain on opening your bowels that gets better each day; spotting of blood; some swelling; discharge from a seton | This is normal. Keep following this guide. |
| AMBER | No bowel movement for 3 days; temperature of 38 °C or more; pain, redness, or swelling getting worse; passing urine with difficulty | Call us today. |
| RED | Heavy bleeding or clots; cannot pass urine at all; severe pain with fever or shivering, especially after banding; feeling faint | Go to the emergency department now. Take this guide with you. |
My contacts Clinic phone: ______________________ Hours: ______________ Out of hours: ______________________ My questions: ____________________________________________________________ [Unit name] [Guide version and review date] |
References
1. Hawkins AT, Davis BR, Bhama AR, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of hemorrhoids. Dis Colon Rectum. 2024;67(5):614-623. doi:10.1097/DCR.0000000000003276
2. Qureshi W, Hoang S, Frye J, Rao SSC. AGA clinical practice update on diagnosis and treatment of hemorrhoids: expert review. Clin Gastroenterol Hepatol. 2026. doi:10.1016/j.cgh.2026.04.008
3. Davids JS, Hawkins AT, Bhama AR, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anal fissures. Dis Colon Rectum. 2023;66(2):190-199.
4. Gaertner WB, Burgess PL, Davids JS, et al. The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Dis Colon Rectum. 2022;65(8):964-985.
Note: references are numbered within this chapter for the pilot. Items marked in square brackets are collected in the Author Fill-in and Verification Log.