• Imperforate Anus
  • Unwilling patient
  • Immunosuppressed patient
  • Absence of anus following surgical excision
  • Stricture
  • Moderate to severe anal pain
  • Prolapsed thrombosed internal hemorroids


  • Severe rectal pain may preclude an awake anoscopy and require sedation
  • Recent acute myocardial infarction
  • Acute abdomen
  • Patients with valvular heart disease or prosthetic valves require prophylactic antibiotics before the procedure
  • Patients with coagulopathy (or anticoagulation medication) if biopsy is to be considered
  • Major rectal trauma
  • Post-operative status (anal surgery)