Hemorrhoids Diagnosis
Classification
- 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
History
- 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
Imaging
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