creation date: 2025-11-10 13:54
tags: Pathologies
Hemorrhoids
Background
Definitions
Hemorrhoids are naturally occurring vascular structures within the anal canal that consist of loose connective tissue, smooth muscle, and blood vessels with arteriovenous connections.
Internal hemorrhoids refer to hemorrhoids that occur in the lower rectum. External hemorrhoids refer to hemorrhoids that occur on the skin around the anus. The dividing landmark is the dentate line.
Etiology and Pathogenesis
As mentioned, hemorrhoids are naturally occurring. They primarily aid in fecal continence by ensuring complete closure of the anal canal during straining, sneezing, or exertion as these actions result in hemorrhoidal engorgement.
Hemorrhoidal disease is thought to involve conditions that result in increased intra-abdominal pressure which result in a decrease in venous return from hemorrhoidal veins leading to pathologic increase in size.
Chronic/persistent straining and/or local trauma to the musculature supporting the hemorrhoids can result in prolapse of hemorrhoids and thus symptoms.
Clinical Presentation
Signs & Symptoms
Approximately 40% of individuals with hemorrhoids are asymptomatic.
Symptoms may include:
- Hematochezia (blood in stool)
- Pain associated with thrombosed hemorrhoid
- Perianal pruritus
- Fecal soilage
Prolapsed internal hemorrhoids may complain of:
- Mild fecal incontinence
- Mucus discharge
- Wetness
- Sensation of fullness in the perianal area
Internal hemorrhoids are typically painless while external hemorrhoids may be painful due to abundance of nerves in the perianal region.
History & Physical Exam
History should be consistent with hemorrhoidal bleeding. Unusual manifestations that should prompt consideration of alternative diagnoses include:
- Melena, dark red blood per rectum, or postural vital sign abnormalities (upper GI)
- Systemic symptoms (malignancy, chronic infection, inflammation)
- Chronic diarrhea with hematochezia and tenesmus (colitis)
- Change in stool frequency caliber, or consistency (colorectal malignancy)
- Painful defecation (not associated with hemorrhoids unless thrombosed)
Physical exam should include digital rectal exam, performed prone or left lateral position at rest and with straining. Clinicians should inspect for:
- External hemorrhoids at the anal verge and perianal area
- Prolapsed internal hemorrhoids
- Skin tags
- Fissures
- Fistulae
- Abscesses
- Neoplasms
- Condylomata
Diagnosis
Criteria
Diagnosis is made by visualization of hemorrhoids.
Internal hemorrhoids can be further graded according to the degree of prolapse:
- Grade I: visualized with anoscopy but does not prolapse below dentate line
- Grade II: prolapses out of anal canal with defecation or straining but reduce spontaneously
- Grade III: prolapses out of anal canal with defecation or straining and requires manual reduction
- Grade IV: irreducible and may strangulate
Work-up
For patients with bright red blood per rectum (BRBPR) or those suspected of having a thrombosed hemorrhoids but were not detected on DRE, anoscopy is used to evaluate the anal canal and distal rectum. This is not typically done in clinic due to lack of instruments.
Laboratory investigations are not routinely indicated.
In specific patient populations, additional work-up is recommended to rule out other etiologies.
In patients <40 years of age, colonoscopy is recommended if the patient has any of the following:
- Concerning clinical manifestations
- Iron deficiency anemia
- Risk factors for colonic disease (PMHx of GI blood loss, IBD, pelvic radiation, FHx IBD, colorectal cancer)
In patients ≥40 years of age, colonoscopy is indicated if there is any suspicion of alternative causes.
Note that upper endoscopy may be indicated based on suspected etiology.
Differential
The differential for bright red blood per rectum includes:
- Bleeding hemorrhoids
- Anal fissures
- Solitary rectal ulcer syndrome
- Polyps
- Rectal prolapse
- Colorectal and anal cancer
- Rectal varices (in cirrhotic patients with portal hypertension)
- Proctitis
Prolapsed tissue may be due to:
- Skin tags
- Condylomata
- Squamous cell neoplasms
Anal pruritus may be due to:
- Hemorrhoids
- Anal abscess
- Fissures
- Fistula
- Anal squamous cell carcinoma
- Other dermatologic diseases
- Infection of anoderm
Red Flags / Complications
Primary complications include:
- Bleeding - resulting in anemia and associated symptoms
- Thrombosis
- Strangulation
Management
Treatment of hemorrhoids is guided by symptoms.
Non-pharmacological
In most patients with new-onset symptoms, conservative management can be successful.
Dietary and lifestyle modifications
- Increased fibre intake (20-30 g of insoluble fibre per day)
- Drink plenty of water (1.5-2 L per day)
- Refrain from straining or lingering on toilet
- Regular physical exercise
- Avoid medications that can cause constipation or diarrhea
- Limit intake of fatty foods or alcohol
Other non-pharmacological symptom treatment includes Sitz baths (warm, shallow bath limited to 15 minutes without addition of salt, lotions, or oils).
Pharmacological / Interventional
Medications are available for symptomatic relief but long-term use should be avoided:
- Topical analgesics (eg. lidocaine-hydrocortisone)
- Topical steroid cream or suppository
- Antispasmodic agents
In patients with grade III-IV or if low-grade is refractory to treatment, referral to specialist may be required.
Interventional techniques used include:
- Rubber band ligation
- Sclerotherapy
- Infrared coagulation of internal hemorrhoids
- Excision of thrombosed external hemorrhoids