Local anesthetics such as lidocaine, bupivacaine, and rupivocaine are routinely used, with or without the addition of adrenaline to delay absorption and prolong the anesthetic effect. Sedatives can be used as adjuncts for patient comfort. A number of techniques have been described for perianal block [ 54 ], and they have been shown to be effective in surgery for fi ssures, fi stulae, as well as excisional and sta­pled hemorrhoidectomy [ 55 , 56 ]. It is perhaps the lack of consensus on the optimum method of infi ltration which prevents the majority of anorectal operations from being done under LA. Rather than blocking one specifi c nerve, these methods aim to block the terminal nerve branches supplying the anal canal from the pudendal nerve: the anococcygeal, inferior rectal, and perineal nerve branches. Prior to injec­tion, the application of EMLA cream perianally has shown to reduce the discomfort associated with the initial needle point [ 57 ]. The majority of described methods resemble the posterior perineal block, fi rst described by Marti [ 58 ] and modifi ed by Gabrielli [ 59 ], whereby local anesthetic infi ltration begins 2 cm from the anal verge