Last reviewed: March 2026
Contents
MDM Templates
Hemorrhoids
Patient presents with rectal pain and bleeding consistent with hemorrhoidal disease. Well appearing without signs of significant hemorrhage. No palpable thrombosed hemorrhoid on exam. History and exam not consistent with anorectal abscess, anal fissure, rectal prolapse, or rectal malignancy.
Plan: WASH regimen — warm water sitz baths 15 minutes TID and after each bowel movement, topical anesthetic (lidocaine), stool softener (docusate 100 mg daily), high-fiber diet. Topical hydrocortisone suppository for symptomatic relief.
Disposition: Discharge with return precautions for heavy bleeding, fever, or worsening pain. Follow up with PCP within 1 week.
Thrombosed External Hemorrhoid
Patient presents with acute onset perianal pain and palpable tender mass consistent with thrombosed external hemorrhoid. Symptom onset within 72 hours.
If within 72 hours of onset and significant pain:
Bedside elliptical excision performed (see procedure note). Patient tolerated procedure well with good pain relief. No significant bleeding post-procedure.
Plan: Sitz baths TID, stool softener, topical lidocaine. Ibuprofen for pain.
Disposition: Discharge with return precautions for heavy bleeding, fever, or worsening pain. Follow up with PCP or surgery within 1 week.
If beyond 72 hours or mild symptoms:
Thrombosed external hemorrhoid is beyond the acute window where excision provides significant benefit. Conservative management is appropriate. Plan: WASH regimen, NSAIDs, stool softener.
Disposition: Discharge. Symptoms expected to improve over 7–10 days. Follow up with PCP. Return for worsening pain, fever, or inability to tolerate PO.
Perianal Abscess
Patient presents with perianal pain and exam reveals a fluctuant, tender mass at the anal verge consistent with simple perianal abscess. Well appearing, afebrile. No induration or erythema extending beyond the abscess margin to suggest deep space infection or necrotizing process.
Bedside incision and drainage performed (see procedure note). Good purulent drainage obtained. No evidence of fistula tract on exploration. Patient tolerated procedure well.
Plan: WASH regimen — sitz baths TID, topical anesthetic, stool softener, high-fiber diet. No antibiotics for simple abscess in immunocompetent patient.
Disposition: Discharge with wound care instructions. Follow up within 48 hours for wound check. Return precautions for fever, worsening pain or swelling, or inability to tolerate PO.
If immunocompromised, cellulitis, or systemic signs:
Patient with perianal abscess and concern for deep space extension given ***, or immunocompromised status. I&D performed with antibiotics initiated — piperacillin-tazobactam 3.375 g IV. Surgery consulted regarding need for operative drainage and advanced imaging.
Anal Fissure
Patient presents with tearing rectal pain during defecation and minor rectal bleeding. Exam reveals a linear tear at the posterior midline. Bleeding is small in quantity. History and exam consistent with acute anal fissure in an immunocompetent patient. Presentation not consistent with anorectal abscess, thrombosed hemorrhoid, or rectal prolapse.
Plan: WASH regimen — sitz baths TID, topical lidocaine, stool softener, high-fiber diet.
Disposition: Discharge. Most acute fissures heal within 4–6 weeks with conservative care. Follow up with PCP. If persistent beyond 6 weeks or recurrent, surgical referral for further evaluation including consideration of lateral internal sphincterotomy. Return for fever, heavy bleeding, or worsening pain.
Rectal Foreign Body
Patient presents after insertion of a foreign body into the rectum. Well appearing without peritoneal signs. No evidence of perforation on exam — abdomen is soft, nontender, without guarding or rigidity.
If successful bedside removal:
Foreign body palpable on digital rectal exam and removed at bedside without complication. Post-removal exam without evidence of rectal perforation, significant mucosal injury, or ongoing hemorrhage. Post-procedure imaging shows no free air or retained foreign material.
Disposition: Discharge with return precautions for abdominal pain, fever, rectal bleeding, or inability to tolerate PO.
If not amenable to bedside removal:
Foreign body not palpable on digital rectal exam or above the reach of bedside extraction. Imaging obtained to evaluate position and rule out perforation. Surgery consulted for operative removal.
Procedure Notes
Perianal Abscess I&D
Indication: Fluctuant perianal abscess
Time Out: Correct patient, correct procedure confirmed
Position: Prone or lateral decubitus
Anesthesia: Local infiltration with 1% lidocaine with epinephrine in a field block surrounding the abscess. Consider procedural sedation for large or deep abscesses.
Approach: Area prepped with chlorhexidine. Cruciate or elliptical incision made over the point of maximal fluctuance as close to the anal verge as possible.
Exploration: Cavity probed with hemostat to break up loculations. Wound irrigated with saline.
Packing: Cavity loosely packed with iodoform gauze strip.
Complications: None. Patient tolerated procedure well.
Hemorrhoid Thrombectomy
Indication: Thrombosed external hemorrhoid within 72 hours of onset with significant pain
Time Out: Correct patient, correct procedure confirmed
Position: Prone or lateral decubitus
Anesthesia: Local infiltration with 1% lidocaine with epinephrine
Approach: Elliptical excision of overlying skin and thrombus (not simple incision — excision prevents re-thrombosis). Hemostasis achieved with pressure.
Closure: Wound left open to heal by secondary intention
Complications: None. Patient tolerated procedure well.
Clinical Education
Hemorrhoid Pearls
Internal hemorrhoids bleed; external hemorrhoids hurt. Internal hemorrhoids arise above the dentate line and are covered by insensate columnar epithelium — they present with painless bright red blood per rectum. External hemorrhoids arise below the dentate line under pain-sensitive squamous epithelium and present with pain, especially when thrombosed.[1]
The WASH regimen is the foundation of ED hemorrhoid management: Warm water sitz baths, Anesthetic (topical lidocaine), Stool softener (docusate), High-fiber diet. This addresses the underlying constipation that drives most hemorrhoidal flares.[2]
Thrombosed external hemorrhoids benefit from excision only within 48–72 hours. After that, the clot is already organizing and conservative management is equivalent. The procedure is elliptical excision (not simple incision and clot extraction, which has a high re-thrombosis rate).[1]
Don’t forget the differential. Rectal bleeding in a patient over 40 with weight loss, change in bowel habits, or iron deficiency anemia warrants outpatient colonoscopy referral even if hemorrhoids are present on exam.
Perianal Abscess Pearls
Antibiotics are not indicated for simple perianal abscess in immunocompetent patients. Adequate drainage is the treatment. Antibiotics add no benefit and don’t prevent fistula formation.[3] Reserve antibiotics for: extensive surrounding cellulitis, immunocompromised patients (diabetes, HIV, chemotherapy), signs of systemic infection, or prosthetic heart valves.
Bedside ultrasound can confirm the diagnosis when the exam is equivocal, particularly for ischioanal abscesses that may not be fluctuant on external palpation. A hypoechoic fluid collection adjacent to the anal canal confirms the diagnosis.
Incise as close to the anal verge as possible. This shortens any potential fistula tract that may form. Up to 50% of perianal abscesses will develop a fistula-in-ano, and patients should be counseled about this at discharge.[3]
Deep space abscesses need the OR. Ischioanal, intersphincteric, and supralevator abscesses are not amenable to bedside drainage and require surgical consultation. Suspect a deep space abscess when the patient has significant pain but minimal external findings, or when CT demonstrates a collection above the levator ani.
| Abscess Type | Location | ED Management |
| Perianal | Subcutaneous, adjacent to anal verge | Bedside I&D |
| Ischioanal | Ischioanal fossa (lateral to sphincter) | OR — surgery consult |
| Intersphincteric | Between internal and external sphincter | OR — surgery consult |
| Supralevator | Above levator ani | OR — surgery consult |
Anal Fissure Pearls
Posterior midline is the classic location. Fissures off the midline (lateral) should raise concern for Crohn disease, HIV, syphilis, tuberculosis, or malignancy — these patients need referral for biopsy.[4]
Most acute fissures heal with conservative management alone. The WASH regimen works for the majority. Topical nitroglycerin 0.4% or topical diltiazem 2% are second-line agents that reduce internal sphincter tone and promote healing in chronic fissures, but these are outpatient therapies.[5]
If the patient is in too much pain for a rectal exam, you can defer it. The diagnosis is clinical — a visible fissure at the anal verge with the appropriate history is sufficient. Aggressive exam in the presence of sphincter spasm is painful and adds little.
Chronic fissures (>6 weeks) need surgical referral. Lateral internal sphincterotomy is the definitive treatment for refractory chronic fissures and has a >95% healing rate.[5]
Pilonidal Abscess
Pilonidal abscess is not a perianal abscess — it occurs in the intergluteal cleft overlying the sacrum/coccyx, not at the anal verge. The distinction matters because pilonidal disease doesn’t involve the sphincter complex and has different surgical follow-up.
ED management is incision and drainage. Make the incision off midline when possible (lateral to the midline pit), as midline incisions heal more slowly. Pack the wound loosely. No antibiotics needed for uncomplicated cases.[6]
Recurrence rate is high (~40–50%). Patients should be counseled about this and referred to surgery for definitive management if recurrent.
Rectal Prolapse
Distinguish full-thickness prolapse from prolapsed hemorrhoids. Full-thickness rectal prolapse has concentric mucosal folds (rings); prolapsed hemorrhoids have radial folds (grooves between cushions). Full-thickness prolapse is a surgical problem.[7]
Reduction technique: Apply granulated sugar to the prolapsed mucosa for 15–20 minutes to reduce edema osmotically, then apply steady circumferential pressure to reduce. If successful, patient can be discharged with urgent surgical follow-up. If irreducible or signs of strangulation (dusky, necrotic mucosa), this is a surgical emergency.
Rectal Foreign Body Pearls
Get imaging before attempting removal. Abdominal X-ray or CT identifies the object’s location, size, and orientation, and rules out perforation (free air). Objects above the rectosigmoid junction generally require operative removal.[8]
Low-lying objects (palpable on DRE) can be attempted at bedside. Use conscious sedation if needed. Position the patient in lithotomy. A Foley catheter passed beyond the object and inflated can break the vacuum seal and facilitate extraction. Bimanual pressure on the lower abdomen can help guide the object toward the anus.
Post-removal imaging is mandatory. A post-extraction X-ray (or CT if concern exists) rules out perforation and retained fragments. Even with uncomplicated removal, delayed perforation can occur.
Maintain a nonjudgmental approach. These patients often delay presentation due to embarrassment, and a professional, matter-of-fact approach improves compliance with follow-up and post-procedure instructions.
Red Flags
Fournier gangrene is the can’t-miss diagnosis. Necrotizing fasciitis of the perineum and perianal region presents with pain out of proportion to exam, crepitus, rapidly spreading erythema, skin discoloration, and systemic toxicity. This is a surgical emergency requiring immediate broad-spectrum antibiotics and operative debridement. Mortality is 20–40% even with treatment.[9]
Perianal complaints in immunocompromised patients deserve a lower threshold for imaging and antibiotics. Neutropenic patients may not form a fluctuant abscess — they can present with induration and tenderness alone. CT is indicated, antibiotics should be broad-spectrum, and surgery should be consulted early.
Rectal bleeding with hemodynamic instability is not a hemorrhoid problem until proven otherwise. Consider lower GI bleed workup, resuscitation, and GI consultation.
References
- Mounsey AL et al. Hemorrhoids. Am Fam Physician. 2011;84(2):204-210. PubMed
- Alonso-Coello P et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol. 2006;101(1):181-188. PubMed
- Steele SR et al. Practice parameters for the management of perianal abscess and fistula-in-ano. Dis Colon Rectum. 2011;54(12):1465-1474. PubMed
- Stewart DB et al. Clinical practice guideline for the management of anal fissures. Dis Colon Rectum. 2017;60(1):7-14. PubMed
- Nelson RL et al. Non-surgical therapy for anal fissure. Cochrane Database Syst Rev. 2012;(2):CD003431. PubMed
- Søndenaa K et al. Patient characteristics and symptoms in chronic pilonidal sinus disease. Int J Colorectal Dis. 1995;10(1):39-42. PubMed
- Bordeianou L et al. Rectal prolapse: an overview of clinical features, diagnosis, and patient-specific management strategies. J Gastrointest Surg. 2014;18(5):1059-1069. PubMed
- Goldberg JE, Steele SR. Rectal foreign bodies. Surg Clin North Am. 2010;90(1):173-184. PubMed
- Eke N. Fournier’s gangrene: a review of 1726 cases. Br J Surg. 2000;87(6):718-728. PubMed
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