Due to increased hydrostatic pressure in hemorrhoidal venous plexus (associated with straining at stool, pregnancy). May be external, internal, thrombosed, acute (prolapsed or strangulated), or bleeding. Treat pain with bulk laxative and stool softeners (psyllium extract, dioctyl sodium sulfosuccinate 100-200 mg/d), sitz baths one to four per day, witch hazel compresses, analgesics as needed. Bleeding may require rubber band ligation or injection sclerotherapy. Operative hemorrhoidectomy in severe or refractory cases.
Medical therapy as for hemorrhoids. Relaxation of the anal canal with nitroglycerin ointment (0.2%) applied tid or botulinum toxin type A up to 20 U injected into the internal sphincter on each side of the fissure. Internal anal sphincterotomy in refractory cases.
Often of unclear cause; may be due to poor hygiene, fungal or parasitic infection. Treat with thorough cleansing after bowel movement, topical glucocorticoid, and antifungal agent if indicated.
Anal Condylomas (Genital Warts) 
Wartlike papillomas due to sexually transmitted papillomavirus. Treat with cautious application of liquid nitrogen or podophyllotoxin or with intralesional interferon α. Tend to recur. May be prevented by vaccination with human papilloma virus (HPV) vaccine.