Hemorrhoids are swollen and inflamed vascular structures or veins around the anus or in the lower rectum.
External hemorrhoids are located closer to the anal verge and are covered with squamous epithelium. It produces symptoms only when thrombosed or when they give rise to large skin tags which make hygiene difficult. Common symptoms are anal pain of acute onset and a palpable lump in the perianal area.
Internal hemorrhoids originate above the dentate line and are covered with rectal or transitional mucosa. It does not cause cutaneous pain. Prolapse of internal hemorrhoids may cause bleeding, mucus discharge, fecal soiling and anal pruritus.


  • 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

Physical Examination

  • 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 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
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