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Key Points

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  1. Hemorrhoidal disease is unusual in childhood and rarely requires operation.

  2. Anal fissures are common and related to constipation. Treating the constipation usually cures the fissure.

  3. Fistula-in-ano presents frequently as recurrent infection, and should be treated operatively with excision.

  4. Rectal prolapse rarely requires operative treatment.

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Introduction

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There are few problems in adult surgical care that create more pain and complaint than perianal problems. By extension, it would seem that children are likely to be as easily disturbed and pained by those conditions that often bear a similar name but may in fact be a little different and require slightly different care. Pain, bleeding, and infection are the common cause of morbidity in these patients, but with prompt evaluation and proper management, prognosis is typically good, except in the rarer cases when these seemingly minor ailments represent a harbinger of more serious disease.

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Minor Perianal Disease

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Hemorrhoidal Disease

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Incidence
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Hemorrhoids in childhood are fairly rare, and so it is hard to find literature that supports any incidence figures. It suffices to say that true hemorrhoids are not commonly encountered in pediatric surgical practice. So-called sentinel piles associated with fissure are considerably more common and often are misdiagnosed as residual hemorrhoidal disease (this is covered below).

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Demographics
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True hemorrhoids are probably a bit more common in boys, since this group is more likely to have problems with chronic constipation in early life.

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Presentation
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Generally these children present with a history of constipation that is complicated by bleeding, bloody toilet water, or streaks of blood in the stool. Physical examination confirms the presence of bluish varicosities on anal examination or gentle internal anoscopy, or possibly thrombosis with a bluish mass.

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Diagnostic Evaluation
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Little more is needed than a good medical history and physical examination unless there is concern that the hemorrhoid is a manifestation of a considerably more serious problem such as portal hypertension.

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Treatment
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Initial treatment in children should be gentle and directed to the underlying constipation if present. This includes stool softeners, a high fiber diet, good hygiene, Sitz baths, and possibly topical steroids. This proves successful in majority of the cases, so it is generally rare to resort to band ligation, sclerotherapy, cryotherapy, or photocoagulation. On very rare occasions, anesthesia and drainage of a painful thrombosed hemorrhoid are needed, just as is required for adults similarly afflicted.

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Outcome
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Conservative medical management solves hemorrhoidal problems for most children. Rarely will a more aggressive surgical procedure be required for good results, although children need to be observed for the same postoperative complications: abscess, cellulitis, bleeding, and the very rare, but gravely serious necrotizing pelvic sepsis, suggested by ...

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