Clinicians who care for pediatric and adolescent patients know that the complaint of perianal swelling is common, and it encompasses a broad spectrum of pathologic processes. Most perianal conditions are benign and are managed by topical treatments. Sometimes, however, perianal swelling can be associated with systemic illness, such as inflammatory bowel disease. Perianal conditions may present with masses, rectal pain, bleeding, and/or itching, all of which can make the exact diagnosis challenging. Reviewing the patient’s history and bowel habits, making note of associated symptoms, and performing a physical examination of the relevant anatomy can often lead to the proper diagnosis and treatment.

• Perianal abscesses are one of the most common pediatric disorders of the perineum.

• Abscesses are often classified according to their location in relation to the levator ani and external anal sphincter. The perianal site is the most common.

• Perianal abscesses often arise from the crypts located at the dentate line.

• An early sign of an abscess is an indurated and tender area at the perineum. Oftentimes an infant’s constant crying or irritability that is worse with diaper changes is the presenting symptom. Erythema can be present, but is not universal. A digital rectal examination can identify the abscess in most patients.

• A pilonidal abscess is an inflammation in the sacrococcygeal region, is often midline, and is sometimes associated with a draining sinus tract. The abscess may begin at the site of an ingrown hair follicle, located 1 to 2 inches above the anus.

• Rupture of an abscess can lead to the formation of a fistula with persistent drainage. With an abscess or fistula, clinicians should consider associated disease, particularly in older children and adolescents.

• Fifteen percent of patients with Crohn disease will present with perianal abscesses or fistulas. In addition, other systemic conditions such as diabetes, chronic granulomatous disease, neutropenia, leukemia, HIV, as well as immunosuppressive therapy may initially present with a perianal abscess.

• Most cases of rectal prolapse, hemorrhoids, perianal fissures, and skin tags are caused by functional constipation. These conditions are often associated with a history of painful defecation associated with large, hard stools. Rectal prolapse, more common in boys, may also be associated with the diagnoses of chronic diarrhea, intestinal parasites, cystic fibrosis, and malnutrition.

• Patients with a history of blood-streaked stool, blood-streaked toilet paper, or frank blood in the toilet, may have a perianal fissure and/or internal hemorrhoids.

• Hemorrhoids are varices of the perirectal venous plexus. Small asymptomatic hemorrhoids are more common in children. Symptomatic hemorrhoids are not very common in the pediatric age group; however, when present, they can cause bleeding, prolapse, discomfort/pain, fecal soiling, and pruritus.

• External hemorrhoids involve the skin of the anus, and the innervation is associated with the skin. Acute pain and bleeding sometimes occurs when external hemorrhoids are infected.

• Internal hemorrhoids are located under the rectal mucosa and can be associated with hematochezia. When present, internal hemorrhoids may be associated with portal hypertension.

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