• Internal hemorrhoids are classified based on the severity of symptoms they cause

Grade I

• Prominent hemorrhoidal vessels that usually bleed, no prolapse

Grade II

• Prolapse with Valsalva maneuver or straining but reduce spontaneously

Grade III

• Prolapse with Valsalva maneuver or straining and require manual reduction

Grade IV

• Permanently prolapsed; manual reduction is not effective
• Usually have both internal and external components and are continuous from skin tag to inner anal canal

• Assess nature, duration and severity of symptoms
  
  • Ask about bleeding, its amount and frequency
  • Ask about presence of prolapsing tissue, its timing and reproducibility

• Elicit possible risk factors for development of hemorrhoidal symptoms
  
  • Low-fiber diets cause small-caliber stools, resulting in straining during defecation and engorgement of hemorrhoids
  • Prolonged sitting on a toilet which may cause a problem in the venous return in the perianal area
  • Pregnancy
  • Advanced age

• The signs and symptoms of hemorrhoids are not specific to the disease, so care must be taken to avoid missing other causes of pathology
• Obtain a good family medical history to assess possibility of familial colorectal neoplastic syndromes, which may indicate a need for a more detailed colonic evaluation

• Perform a careful anorectal evaluation
• Inspect the entire perianal area
  
  • Reassure the patient and warn him/her before doing any maneuvers
  • Gently spread the buttocks to visualize the anoderm and the distal anal canal
  • Examine for hemorrhoids and its possible complications eg skin tags, thrombosed external hemorrhoids, incarcerated prolapse of the rectal mucosa
  • Inspect area for other lesions eg fissures, perianal dermatitis, abscess, fistula, neoplasms, condylomata

• Perform a digital rectal exam
  
  • May be able to identify areas of induration or ulceration

Anoscopy

• Anoscopy is recommended to establish the diagnosis of hemorrhoids
  
  • It is compulsory for evaluating internal hemorrhoids
  • Instruct patient to do a Valsalva maneuver to observe prolapse

Other Visualization Procedures

• Colonoscopy or barium enema may be needed in the following situations:
  
  • Bleeding that is not characteristic of hemorrhoids, eg blood admixed with feces, dark blood
  • Patient with significant risk factors for colonic malignancy
  • No identified anal source of bleeding
  • Anemia

• Some experts recommend that anoscopy or flexible sigmoidoscopy be done for all patients with rectal bleeding