In patients with multiple or recurrent fistulas Crohn's disease should be considered as this may be an initial presentation of this disease process. The illustration from Corman's textbook demonstrates the normal anatomic position of the venous cushions in the anal canal. These cushions are located on the right posteriorly, right anteriorly and left anteriorly. This anatomic arrangement explains the common presentation of both internal and external hemorrhoid disease in these anatomic positions. This slide shows congested and edematous external hemorrhoids at the right posterior, right anterior and left anterior position.
External hemorrhoids are contiguous with perianal skin.
These rarely require surgical intervention and are treated conservatively with Sitz bath and local medication. The internal hemorrhoids are prolapsed. The internal hemorrhoids would be classified as stage II if they spontaneously reduce, stage III if they reduce with manual manipulation, and stage IV if they are non-reducible. Stage I hemorrhoids are seen on anoscopy but do not prolapse. Visualization internal hemorrhoids during the physical exam is accomplished by asking the patient to strain.