What is the most likely cause of bright red blood on tissue after wiping, with normal digital rectal exam findings?

The presentation of bright red blood on tissue after wiping, coupled with a normal digital rectal exam, suggests that the bleeding is occurring at or near the anal opening rather than from deeper within the rectum or colon. In this context, internal hemorrhoids are a likely cause of such symptoms.

Internal hemorrhoids occur due to the engorgement of vascular cushions located within the anal canal. When these internal hemorrhoids bleed, the blood is typically bright red and may be noted on toilet paper after wiping. Since internal hemorrhoids are not palpable during a digital rectal exam, normal findings on this exam align with the likelihood of internal hemorrhoids being the source of bleeding.

While other conditions like anal fissures and external hemorrhoids can also present with bright red blood, they often show additional signs or symptoms. Anal fissures are usually accompanied by pain during defecation, and bleeding is often mixed with stool rather than purely on tissue. External hemorrhoids can also bleed, but they usually become obvious during physical examination and may present with symptoms like pain, especially when thrombosed. A perianal abscess typically presents with more significant pain, swelling, and tenderness, with a potential for more severe symptoms.

Thus, internal hemorrhoids, with their characteristic presentation