Examination

This should be carried out in a well-lit area with the patient in the left lateral position. Look for obvious abscess or areas of induration or pain to suggest a deeper abscess.

Any haemorrhoids should be noted and classified, and anal fissure looked for (presence of a sentinel pile hints toward a fissure). Assess appearance of any haemorrhoids (purplish tender grape-like haemorrhoids tend to be thrombosed; black haemorrhoids tend to be necrotic). Always look in the natal cleft for the presence of any pilonidal sinuses.

This will often be normal if the patient has haemorrhoids, and will often be painful and poorly tolerated if they have an anal fissure or abscess.

This must be carried out, either by the surgical team in the ED or in a follow-up outpatient clinic, depending on local protocols. Haemorrhoids will appear at 3, 7 and 11 o’clock when the patient is supine [3].