Left lateral, right anterior, and right posterior hemorrhoidal plexuses
External hemorrhoids cause pain when they thrombose
• Distal to the dentate line, covered by sensate squamous epithelium; can cause pain, swelling, and itching
Internal hemorrhoids cause bleeding or prolapse
• Primary – slides below dentate with strain
• Secondary – prolapse that reduces spontaneously
• Tertiary – prolapse that has to be manually reduced
• Quaternary – not able to reduce
Tx: fiber and stool softeners (prevent straining); sitz baths
Thrombosed external hemorrhoid → lance open (if > 72 hours) or elliptical excision (if < 72 hours) to relieve pain
Surgical indications: recurrence, thrombosis multiple times, large external component
External hemorrhoids can be resected with elliptical excision
Can band primary and secondary internal hemorrhoids
• Do not band external hemorrhoids (painful)
Surgery for tertiary and quaternary internal hemorrhoids – 3 quadrant resection
• Need to resect down to the internal anal sphincter (do not go through it)
• Postop – sitz baths, stool softener, high-fiber diet
RECTAL PROLAPSE
Starts 6–7 cm from anal verge
Secondary to pudendal neuropathy and laxity of the anal sphincters
↑ with female gender, straining, chronic diarrhea, previous pregnancy, and redundant sigmoid colons
Prolapse involves all layers of the rectum
Medical Tx: high-fiber diet
Surgical Tx:
• Perineal rectosigmoid resection (Altemeier) transanally if patient is older and frail
• Low anterior resection and pexy of residual colon if good condition patient
![](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/image00632.gif?w=960)
CONDYLOMATA ACUMINATA
Cauliflower mass; papillomavirus (HPV)
Tx: laser surgery
ANAL FISSURE
Caused by a split in the anoderm
90% in posterior midline
Causes pain and bleeding after defecation; chronic ones will see a sentinel pile
Medical Tx: sitz baths, bulk, lidocaine jelly, and stool softeners (90% heal)
Surgical Tx: lateral subcutaneous internal sphincterotomy
Fecal incontinence is the most serious complication of surgery
Do not perform surgery if secondary to Crohn’s disease or ulcerative colitis
Lateral or recurrent fissures – worry about inflammatory bowel disease
![](https://i0.wp.com/basicmedicalkey.com/wp-content/uploads/2017/06/image00633.gif?w=960)
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