Anal Fissures, Hemorrhoids, Skin Tags, and Pilonidal Cysts: A Complete Guide

Anal Fissures

Definition: Linear tears in the anoderm (distal anal canal mucosa).

• Causes: Hard stools (constipation), diarrhea, childbirth, anal trauma.
• Symptoms: Sharp, tearing pain during/after bowel movements; bright red blood on paper/stool; sphincter spasm.
• Treatment: High‑fiber diet, stool softeners, sitz baths, topical nitroglycerin/nifedipine (reduce sphincter tone), botulinum toxin injection, lateral internal sphincterotomy (chronic).

Hemorrhoids

Definition: Swollen vascular cushions in the anal canal (internal) or under perianal skin (external).

• Causes: Straining, chronic constipation/diarrhea, pregnancy, obesity, prolonged sitting, aging.
• Symptoms: Painless bright red bleeding (internal); pain, swelling, thrombosis (external); itching, mucus discharge, prolapse.
• Treatment: Fiber, fluids, sitz baths, topical steroids; office procedures (rubber band ligation, sclerotherapy, infrared coagulation); excisional hemorrhoidectomy (severe).

Perianal Skin Tags

• Definition: Redundant skin folds at anal verge, often residual from resolved thrombosed external hemorrhoids or healed fissures.
• Symptoms: Usually asymptomatic; may cause hygiene difficulty, itching, irritation.
• Treatment: Conservative (hygiene, barrier creams); excision if symptomatic (office procedure).

Pilonidal Cysts / Sinus

• Definition: Infected tract/cavity in natal cleft (between buttocks), often containing hair nests.
• Causes: Hair penetration, friction, prolonged sitting, obesity, deep natal cleft.
• Symptoms: Pain, swelling, purulent drainage, fever if abscessed.
• Treatment: Incision & drainage for abscess; definitive excision with primary closure or open healing (Bascom cleft lift, Karydakis flap) for chronic/recurrent disease.

When to See a Clinician

• Rectal bleeding (never assume hemorrhoids — rule out neoplasia).
• Severe pain, fever, inability to defecate.
• Recurrent or non‑healing lesions.
• Change in bowel habits, weight loss.