A hernia is a medical condition where an organ or fatty tissue pushes through a weak spot in the surrounding muscle or connective tissue. A “high anal hernia” is a less frequently discussed form, referring to a protrusion occurring high in the region of the anus, within the complex anatomy of the pelvic floor. It is classified as a type of perineal hernia, a rare defect that requires precise diagnosis and specialized treatment.
Defining the Anatomy of a High Anal Hernia
This type of hernia is defined by its location in the pelvic floor, specifically involving the muscles that support the rectum and anus. The “high” designation indicates that the protrusion occurs superiorly within the perineum, often extending into the ischiorectal (ischioanal) fossa. This fossa is a wedge-shaped, fat-filled space on either side of the anal canal, situated just below the pelvic diaphragm.
The structural weakness that allows the hernia to form typically involves the levator ani muscle, which is a broad muscle forming a significant part of the pelvic floor. When a defect or tear occurs in this muscle, it can result in a translevator perineal hernia, pushing into the deep ischiorectal fossa. The contents that herniate through this defect can include retroperitoneal fat, a segment of the bowel, or other pelvic organs.
This differs from more common hernias, such as inguinal hernias, which occur in the groin area. The delicate musculature and deep location near the anal canal make the high anal hernia a challenging condition. The herniation site is lateral to the anal canal, often appearing between the levator ani muscle and other surrounding structures.
Recognizing Symptoms and Underlying Causes
Patients with a high anal hernia often experience symptoms related to the mass effect and pressure on surrounding structures. The most common indicator is a soft, palpable mass or swelling located adjacent to the anus, which may protrude further with straining. This mass is often reducible, meaning it can sometimes be gently pushed back into the body.
Localized pain or discomfort is a primary symptom, often intensifying during activities that increase abdominal pressure, such as sitting, coughing, or heavy lifting. Patients frequently report difficulty or straining during defecation, known as tenesmus, or chronic constipation. If a segment of bowel becomes trapped, the patient may experience sudden, severe abdominal pain and signs of a bowel obstruction.
The underlying causes stem from a weakening of the pelvic diaphragm’s musculature. A significant risk factor is previous surgery in the perineal region, such as procedures involving the removal of the coccyx, which can leave a structural gap. Chronic, excessive straining from long-term constipation, chronic coughing, or urinary obstruction also contributes by repeatedly placing high pressure on the pelvic floor. Most acquired cases result from age-related changes or trauma that weaken the levator ani muscle over time.
Diagnostic Methods
Confirming the presence and exact location of a high anal hernia requires a thorough physical examination followed by advanced imaging studies. A physician performs a clinical assessment, including a digital rectal examination, to feel for the defect and the presence of a soft, sometimes tender, mass next to the anal canal. The examination helps determine the size and reducibility of the protrusion.
Imaging techniques are essential to precisely map the hernia’s anatomy and contents. Computed Tomography (CT) scans of the pelvis are often used initially, though they can sometimes misinterpret the herniated tissue, potentially mimicking a mass. Magnetic Resonance Imaging (MRI) is the superior diagnostic tool, providing high-resolution images that clearly delineate the pelvic floor muscles. MRI confirms the defect in the levator ani and identifies the specific contents of the hernia sac. Dynamic MRI may also be used to observe the defect during straining, which better reveals the extent of the herniation.
Management and Treatment Options
Treatment for a high anal hernia is predominantly surgical due to the risk of complications, such as incarceration or strangulation of the herniated tissue. The main goal of the procedure is to reduce the contents of the hernia sac, pushing the protruding tissue back into the abdominal or pelvic cavity. Following reduction, the surgeon must repair and reinforce the defect in the pelvic floor musculature.
Various surgical techniques exist, but they all focus on closing the weakness. Surgeons often utilize the patient’s own tissue, such as a muscle flap, or a synthetic prosthetic mesh for long-term reinforcement. The use of a mesh helps bridge the gap in the levator ani muscle, reducing the likelihood of recurrence. For patients with mild symptoms or those awaiting surgery, conservative management plays a temporary role, including aggressive management of chronic constipation through diet, stool softeners, and laxatives to minimize straining.