She describes her personal hygiene as scrupulous. Examination reveals marked erythema and excoriation of the perianal area. Work-up including barium enema and sigmoidoscopy fails to reveal any other colorectal pathology. Initially, the protrusion spontaneously reduced, but on several occasions recently, manual reduction has been required. Also, she has noted some recent episodes of anal incontinence.
Examination is unremarkable except for a somewhat lax internal sphincter.