Over 40% of children with Crohn's disease (CD) develop perianal lesions (skin tags and/or fissures), which are associated with the risk of perianal fistula. It is unknown how reliably perianal symptoms predict perianal lesions. We recruited pediatric patients with CD who were undergoing colonoscopy for clinical indications. Patients self-reported recent perianal symptoms. We retrospectively reviewed the perianal exam documented on colonoscopy reports and in the electronic health record to obtain details of perianal lesions if present. Thirty-three patients were included: median age 15.6 years (interquartile range 12.9-17.5), 27% female, 80% White. There was no association between any perianal symptom and the presence or absence of any perianal lesion (p = 0.85), suggesting the presence or absence of perianal pain and/or anal discharge does not predict whether a patient with CD has perianal lesions. This raises the importance of perianal examination, regardless of symptoms, for identifying perianal lesions early and enabling treatment aimed at preventing perianal fistula development in patients with CD.