External piles form at or just outside the anal orifice. They are invariably covered with skin, not mucosa, and this is endowed with ordinary cutaneous sensation they may be extremely painful. External piles may be divided into two groups—acute thrombosed external piles or anal haematomas, and chronic anal skin tags.
ANAL SKIN TAGS
Anal skin tags are exceedingly common, and it is impossible to examine more than a few rectal patients without encountering a varied assortment of anal skin tags. In any individual case they may be single or multiple, and may vary from a slight excrescence or skin fold to grossly projecting tags. An important practical distinction is between idiopathic skin tags, may which are not associated with any obvious causal condition, and secondary skin tags, occurring in connection with an anal fissure or pruritus ani. Idiopathic skin tags may possibly represent resolved anal haematomas, but in many instances there is nothing in the patient’s history to suggest it. t Usually idiopathic tags are soft and pliable and are covered by normal skin. A secondary skin tag found in relation to a fissure-in-ano is normally stiff with oedema when the fissure is open, but after healing has taken place it becomes more flaccid like any other ordinary skin tag. Some of the grossest examples of skin tags are found in association with pruritus ani; they are to be regarded as simply oedematous, infected skin rugae, and the anal and perianal skin in these cases shows the typical dermatatis in pruritus ani.
A careful examination will quickly differentiate anal skin tags from other lesions at the anus such as anal warts, condylomata or a carcinoma, and will indicate whether they are part of a pruritus ani, are associated with an anal fissure or are occurring quite idiopathically.
Idiopathic anal skin tags require no treatment as a rule. Exceptionally, they may be so large as to become something of a nuisance to the patient after defaecation in cleansing the anal region , or he may complain of discomfort in one or more of them and ask for its removal. This is a simple procedure which can, if necessary, be performed under local anaesthesia. Often, however, it is necessary to remove associated internal haemorrhoids by a formal ligature and excision operation, the skin cut being made sufficiently wide to involve as many of the skin tags as possible; it may be worth sacrificing one of the skin bridges if required to facilitate wider excision of the cutaneous swellings.