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Anal hematoma

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anal hematoma thrombosed external hemorrhoid patient information

An anal hematoma is usually a small blood clot under the skin at the anal edge, also called a thrombosed external hemorrhoid or perianal thrombosis. It commonly causes a sudden, painful, blue-purple lump just outside the anus, often after constipation/straining, diarrhea, heavy lifting, or prolonged sitting.
  • Pain often peaks in the first 48-72 hours and then improves over about 4-5 days. The lump can take days to a few weeks to fully shrink. ASCRS patient information
  • Usual self-care: warm sitz baths, avoiding straining, fluids and fiber to keep stools soft, and non-opioid pain relief if safe for you. Do not try to puncture or drain it yourself.
  • If the pain is severe and began within about 72 hours, a clinician may offer a small procedure under local anesthetic to remove the clot. Acute hemorrhoidal crisis review
  • Get urgent medical assessment for fever, spreading redness, pus, worsening swelling, heavy or persistent rectal bleeding, severe pain with inability to pass stool/urine, or if you are immunocompromised or taking blood thinners. These can suggest an abscess or another condition rather than a simple hematoma.
A surgeon’s textbook describes external anal plexus hematoma as causing severe anal pain and swelling, often resolving spontaneously within around five days, with evacuation considered for extreme localized pain. Fischer's Mastery of Surgery, 8th ed.

Surgery notes

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thrombosed external hemorrhoid

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ASCRS thrombosed external hemorrhoid clinical practice guideline excision 72 hours

Anal hematoma: surgical notes

Definition

An anal hematoma is a localized collection of clotted blood beneath the perianal skin, most often termed a thrombosed external hemorrhoid. It presents as an acute, tender bluish-purple perianal swelling.

Indications for surgical treatment

Consider early surgical excision/evacuation when:
  • Severe, disabling pain
  • Symptom onset usually within 48-72 hours
  • Large tense thrombosis
  • Skin necrosis, spontaneous rupture, or persistent bleeding
  • Recurrent thrombosis or failure of conservative treatment
  • Diagnosis is uncertain and specialist assessment is needed
Patients whose pain is clearly improving, or who present after about 72 hours, are generally treated conservatively because the clot becomes organized and procedure-related pain may outweigh benefit. However, severe ongoing pain or necrosis still warrants surgical review. Acute hemorrhoidal crisis review

Preoperative assessment

  • History: exact onset, severity of pain, bleeding, constipation/straining, diarrhea, heavy lifting, anticoagulant use, previous hemorrhoids.
  • Examination: inspection of perianal region for a tender blue-black lump, skin ulceration, abscess, fissure, prolapsed hemorrhoid, or suspicious lesion.
  • Check for red flags: fever, cellulitis, discharge, fluctuance, immunosuppression, anticoagulation, unexplained weight loss, altered bowel habits.
  • Routine investigations are usually unnecessary for a typical small external thrombosis. Check coagulation status selectively in patients taking anticoagulants or with bleeding risk.

Procedure: excision of thrombosed external hemorrhoid

Anaesthesia: Local infiltration, often sufficient for an office or minor-procedure setting.
Position: Left lateral or prone jackknife.
Preparation: Perianal antiseptic preparation and sterile draping.
Steps
  1. Identify the thrombosed external hemorrhoid.
  2. Infiltrate local anesthetic around, rather than directly into, the painful thrombosed tissue.
  3. Make an elliptical incision over the lesion.
  4. Excise the overlying skin ellipse and remove the entire clot and thrombosed hemorrhoidal tissue.
  5. Achieve hemostasis with pressure or cautery as needed.
  6. Leave the wound open or selectively approximate it, according to surgeon preference and wound characteristics.
  7. Apply light dressing.
Key surgical point: Simple incision alone may leave residual clot and is associated with recurrence. Complete excision/evacuation is generally preferred when intervention is selected. A family medicine text reports that office excision, rather than incision alone, results in earlier symptom resolution and lower recurrence. Textbook of Family Medicine, 9th ed.

Postoperative care

  • Oral non-opioid analgesia if appropriate
  • Warm sitz baths, usually several times daily and after bowel movements
  • High-fiber diet, adequate fluids, and stool softener as required
  • Avoid straining and prolonged time on the toilet
  • Light dressing and local hygiene
  • Review if pain worsens, fever develops, bleeding is persistent, or purulent discharge occurs

Complications

  • Pain
  • Bleeding or hematoma
  • Infection or perianal abscess
  • Delayed healing
  • Skin tag
  • Recurrence
  • Rarely, fissure or fistula

Outcome

Pain commonly improves rapidly after successful clot removal. Without surgery, the pain typically peaks at 48-72 hours and improves over several days; the lump may take longer to resolve. ASCRS hemorrhoid information

One-line exam answer

Acute painful anal hematoma is treated by early elliptical excision and complete evacuation of the clot under local anesthesia when severe pain is present within about 72 hours; otherwise conservative treatment with sitz baths, analgesia, fiber, and stool softening is appropriate.
Recent evidence note: a 2026 systematic review/meta-analysis compared operative with nonoperative treatment, but management remains individualized because the underlying evidence base is limited (PMID 40576944).
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