'Bumps Down Under:' Hemorrhoids, Skin Tags and All Things Perianal

Melissa M. Alvarez-Downing; Giovanna da Silva


Curr Opin Gastroenterol. 2021;38(1):61-66. 

In This Article

Abstract and Introduction


Purpose of Review: There continues to be a concentrated effort to improve treatment options readily available for some of the most common perianal diseases: hemorrhoids, anal fissure and anal fistula. The emphasis remains on therapies that definitively address the underlying pathology yet minimize pain and risk of incontinence, have a short recovery period, and are cost-effective. In this analysis, recent developments in the literature are reviewed.

Recent Findings: Treatment of early stage hemorrhoidal disease remains the same. For grades II–IV disease, hemorrhoidal vessel ligation/obliteration with laser or bipolar energy are reported. For more advanced diseases, modifying the technique for hemorrhoidectomy to improve postoperative complications and pain is described. For anal fissure, a stepwise method continues to be the mainstay of treatment (initiating with vasodilators, followed by botox, and ultimately sphincterotomy), which decreases the risk of incontinence with proper patient selection and technique. Management of anal fistula continues to be challenging, balancing cure vs. risk of harm. Recent developments include modifications to ligation of intersphincteric fistula tract procedure and use of laser to obliterate the tract.

Summary: Advancements in managing benign anorectal disease are ongoing. Several reports are novel, whereas others involve enhancing well-established treatment options by either operative technique or patient selection.


Benign anorectal diseases – hemorrhoids, anal fissure, and fistula – are not only common, but can significantly impact the quality of life of those who experience symptoms. There remains a constant challenge in the treatment of these diseases – quickly alleviate symptoms and definitively treat the problem yet minimize pain/discomfort and maintain fecal continence. In this quest to find a 'painless' treatment for these diseases with minimal to no effect on continence, there are many techniques, old and new, which have been described in the literature.