Abdominal wall hernias — a protrusion of abdominal contents (usually bowel or omentum) through a weak area of the abdominal wall. Increased intra-abdominal pressure (chronic cough, straining, heavy lifting, obesity, pregnancy, ascites) enlarges them.

Hernia states

• Reducible — contents return to the abdomen when lying down or with gentle pressure
• Incarcerated (irreducible) — contents are trapped; may cause bowel obstruction
• Strangulated — blood supply is cut off → ischemia and necrosis within hours — surgical emergency

Hemorrhoids — dilated vascular cushions in the anal canal.

• Internal (above the dentate line — no pain fibers): painless bright red bleeding with defecation, prolapse. Graded I–IV (I bleed only; II prolapse and reduce spontaneously; III need manual reduction; IV cannot be reduced)
• External (below the dentate line): itching, swelling; painful when thrombosed (tense bluish lump)
• Causes: straining, constipation, prolonged sitting on the toilet, low-fiber diet, pregnancy, obesity, heavy lifting

Other anorectal disorders

Hernias

• Bulge that enlarges with coughing, standing, or straining and disappears when lying down; aching or heaviness
• Warning signs of strangulation: severe, constant pain, a tense, tender, red or dusky bulge that will not reduce, fever, tachycardia, and obstruction signs — nausea, vomiting, distension, and no passage of stool or flatus

Anorectal

• Bleeding (color, amount, relation to stool), pain (timing with defecation), itching, swelling, discharge, prolapse
• Bowel habits, straining, fiber and fluid intake, anal sexual history, Crohn disease
• Rectal bleeding in adults 45 or older, or with iron-deficiency anemia or change in bowel habits, needs evaluation for colorectal cancer — do not assume it is "just hemorrhoids"

Hernias

• Elective repair for symptomatic hernias: herniorrhaphy (suture repair) or hernioplasty with mesh, open or laparoscopic
• Watchful waiting is acceptable for minimally symptomatic inguinal hernias in men; femoral hernias are repaired because of strangulation risk
• Incarcerated hernia: gentle reduction by a provider may be tried only if strangulation is not suspected
• Strangulated hernia: emergency surgery, possibly with bowel resection
• Trusses are not a substitute for repair
• Infant umbilical hernia: most close on their own in early childhood; repair if it persists into later childhood (commonly by about 4–5 years), is very large, or incarcerates. Do not tape coins or bands over it

Hemorrhoids

• First-line: high-fiber diet (about 25–35 g/day), fluids, fiber supplements (psyllium), with an osmotic laxative (polyethylene glycol) if needed — stool softeners such as docusate have weak evidence, avoid straining
• Warm sitz baths (about 10–15 minutes, 2–3 times a day and after bowel movements) relieve pain and swelling and relax the sphincter
• Topical agents for short-term symptom relief: hydrocortisone (limit to about 1 week — skin thinning), local anesthetics, witch hazel pads
• Office procedures for grades I–III internal hemorrhoids: rubber band ligation (most common), sclerotherapy, infrared coagulation. After banding: dull ache, possible delayed bleeding about 1–2 weeks later when the band falls off (higher risk with anticoagulants or antiplatelet drugs), and urinary retention. Report severe pain, fever, or inability to void after banding — rare pelvic sepsis
• Hemorrhoidectomy for large grade III–IV, mixed, or refractory hemorrhoids
• Thrombosed external hemorrhoid: excision within about 72 hours of onset gives fastest relief; later, conservative care

Anal fissure

• Fiber, sitz baths, topical anesthetics
• Topical nitroglycerin (headache, dizziness and hypotension — rise slowly; apply with a gloved or covered finger; not with PDE-5 inhibitors such as sildenafil) or topical diltiazem/nifedipine (fewer headaches)
• Botulinum toxin injection; lateral internal sphincterotomy for chronic fissures (small risk of incontinence)

Anorectal abscess and fistula

• Abscess: incision and drainage (antibiotics added for cellulitis, diabetes, immunosuppression, or systemic signs)
• Fistula: fistulotomy (laying the tract open) is most common for simple fistulas; seton placement, advancement flap, or other sphincter-sparing procedures for complex fistulas (protect continence)

Pilonidal disease — drainage or excision; hair removal to reduce recurrence.

Listed in priority order.

1. Recognize strangulation and obstruction — severe constant pain, dusky bulge, vomiting, distension, no stool or flatus: keep NPO, notify the provider immediately, prepare for emergency surgery; do not force reduction
2. After hernia repair
   • Urinary retention is common (anesthesia, pain, older men) — monitor voiding, bladder scan, catheterize as ordered
   • Hematuria or painful urination after inguinal repair may indicate bladder injury — report promptly
   • Scrotal swelling after inguinal repair: ice packs and scrotal support/elevation
   • Deep breathing; splint the incision with a pillow when coughing or sneezing; avoid straining
   • Fiber and an osmotic laxative as ordered to prevent straining
3. After anorectal surgery (hemorrhoidectomy, fistula, fissure)
   • Pain is often severe: scheduled analgesia (opioid-sparing where possible), ice packs early, then sitz baths
   • Urinary retention — monitor voiding; limit excess IV fluids per order
   • Bleeding — check dressings and pads; report heavy bleeding
   • First bowel movement is often painful: give analgesic beforehand, fiber and a laxative as ordered, adequate fluids; avoid delaying defecation (hard stool)
   • Side-lying or prone positioning; flotation cushion if needed (avoid prolonged sitting on rings)
4. Skin care — gentle cleansing with water after each stool, pat dry, barrier cream

Hernia repair

• Avoid heavy lifting and strenuous activity for the period the surgeon advises, even if pain is gone — the restriction period varies by repair type and surgeon (often several weeks after open repair); light daily activity and walking are encouraged
• Walk daily; return to desk work usually within 1–2 weeks
• Prevent constipation and straining; treat chronic cough; stop smoking; manage weight
• Report fever, wound redness or drainage, increasing pain, a bulge at the site, or difficulty urinating

Hemorrhoids and fissures

• Increase fiber and fluids; respond promptly to the urge to defecate; do not strain or sit on the toilet for long periods (e.g., using phones)
• Sitz baths in plain warm water; avoid harsh soaps, scented wipes, and vigorous rubbing
• Use topical steroids only for the short period prescribed
• Report heavy bleeding, black stools, fever, or increasing pain

Pruritus ani

• Keep the area clean and dry; wash with water after bowel movements and pat dry; cotton underwear
• Avoid hot water, perfumed products, and scratching; limit caffeine and other foods that trigger itching; use prescribed creams only as directed

After sphincter surgery or rectal resection — pelvic floor exercises and bowel routine help with urgency and fecal incontinence; report persistent leakage.

• Femoral hernia: more common in women, highest strangulation risk — repair
• Strangulation: severe constant pain, dusky bulge, no stool or flatus, vomiting → emergency surgery
• After inguinal repair: urinary retention, scrotal swelling (ice, support), report hematuria
• Avoid heavy lifting for the period the surgeon advises (varies by repair), even when pain has resolved
• Internal hemorrhoids: painless bright red bleeding; external thrombosed: painful
• Hemorrhoid care: fiber and fluids, sitz baths 2–3 times daily, short-term topical steroids
• Anal fissure: pain with defecation; topical nitrates or calcium channel blockers
• Abscess → incision and drainage; fistula → fistulotomy or seton
• Postoperative anorectal care: analgesic before the first bowel movement, fiber with an osmotic laxative if needed, sitz baths
• Pruritus ani: clean and dry
• Rectal bleeding in older adults needs colorectal cancer evaluation
• Infant umbilical hernia: usually closes by itself — observe