Hemorrhoids
Symptomatic engorgement of internal or external hemorrhoidal cushions; common cause of rectal bleeding.
Also known as: hemorrhoids, piles, internal hemorrhoids, external hemorrhoids, thrombosed hemorrhoid
Overview
Symptomatic engorgement and prolapse of the anal cushions (vascular structures in the anal canal). Internal hemorrhoids arise above the dentate line (visceral innervation — painless); external hemorrhoids arise below the dentate line (somatic innervation — painful when thrombosed).
Epidemiology
Lifetime prevalence 50-75%. Peak age 45-65. Equal sex distribution; pregnancy markedly raises incidence in women.
Keep reading — start your free trial
You've read your 2 free diagnosis previews. Create your free account to unlock the full Hemorrhoids outline — plus all 514 diagnoses, 5,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
Risk factors
- Chronic constipation and straining
- Low-fiber diet
- Prolonged sitting on the toilet
- Pregnancy and childbirth
- Obesity
- Heavy lifting
- Chronic diarrhea
- Cirrhosis with portal hypertension (more often anorectal varices than true hemorrhoids)
Pathophysiology
Increased intra-abdominal pressure and straining engorge the anal vascular cushions; weakening of the connective tissue (Treitz muscle/Parks ligament) allows downward displacement and prolapse. Mucosal trauma during defecation causes bleeding.
Clinical presentation
Symptoms
- Internal: PAINLESS bright red blood per rectum on tissue or coating stool; sensation of fullness; prolapse with defecation
- External: PAINFUL perianal lump if thrombosed; itching, bleeding, hygiene difficulty
- Mucus discharge, soiling
- Pruritus ani
Signs / physical exam
- External hemorrhoids: visible on perianal inspection; thrombosed appears as tender purple-black firm lump
- Internal hemorrhoids: not palpable on DRE (soft veins compress); seen on anoscopy
- Prolapsed internal hemorrhoids visible externally
Classic findings
Painless bright red blood on toilet paper after defecation (internal); tender perianal lump (thrombosed external).
Differential diagnosis
- Anal fissure — Severe sharp pain WITH defecation; small streak of bright red blood on tissue; posterior midline tear on exam
- Perianal abscess — Severe constant pain, fever, fluctuant tender perianal mass
- Anal fistula — Recurrent drainage of pus/blood from perianal opening; prior abscess
- Anal or rectal cancer — Older patient, mass, weight loss, change in bowel habit; biopsy any non-healing lesion
- Rectal prolapse — Full-thickness protrusion of rectal wall, concentric rings (vs radial folds of hemorrhoid)
- Pruritus ani — Itching without bleeding; multiple causes
- Inflammatory bowel disease (perianal Crohn) — Skin tags, fistulas, fissures in young patient with chronic diarrhea
- Condyloma acuminata (HPV) — Cauliflower-like perianal lesions
Diagnostic workup
Diagnostic criteria
Clinical diagnosis. Internal hemorrhoids graded by Goligher classification I-IV: I (no prolapse), II (prolapse with defecation, reduces spontaneously), III (prolapse requiring manual reduction), IV (irreducible prolapse).
Labs
- CBC if anemia suspected (chronic blood loss)
Imaging
- Anoscopy — direct visualization of internal hemorrhoids
- Flexible sigmoidoscopy or colonoscopy if age ≥45, alarm features (weight loss, change in bowel habit, anemia, family history of CRC) or atypical/persistent bleeding — to exclude malignancy and proximal sources
- DRE — assess for masses but does NOT exclude hemorrhoids (compressible)
Diagnostic algorithm
| Goligher Grade | Description | Preferred Treatment |
|---|---|---|
| I | Bleed without prolapse | Conservative; consider sclerotherapy or band ligation if refractory |
| II | Prolapse with defecation, reduces spontaneously | Rubber band ligation |
| III | Prolapse requiring manual reduction | Rubber band ligation or hemorrhoidectomy |
| IV | Irreducible / chronic prolapse | Excisional hemorrhoidectomy |
Treatment
First-line
- Dietary fiber (25-35 g/day) and adequate hydration
- Bulk-forming laxative — psyllium, methylcellulose
- Avoid prolonged toilet sitting and straining
- Sitz baths 15 min several times daily
- Topical analgesics and astringents (witch hazel, lidocaine)
- Short-course topical hydrocortisone (limit to <1 week to avoid skin atrophy)
Grade I-II internal hemorrhoids — refractory to conservative measures
- Rubber band ligation — most effective office procedure
- Sclerotherapy — phenol or ethanolamine injection
- Infrared photocoagulation
Grade III-IV internal hemorrhoids or refractory disease
- Excisional hemorrhoidectomy (Milligan-Morgan or Ferguson) — most effective but most painful
- Stapled hemorrhoidopexy (PPH) — less postoperative pain, higher recurrence
- Doppler-guided hemorrhoidal artery ligation (HAL/THD)
Acutely thrombosed external hemorrhoid
- If presenting within 48-72 h with severe pain: excision (NOT incision and drainage) under local anesthesia
- After 72 h or improving: conservative management — sitz baths, analgesia, stool softeners; thrombus resorbs over weeks
Second-line / adjunct
- Oral phlebotonics (flavonoids) — modest benefit in some studies; not FDA-approved in US
- Treat underlying constipation aggressively
- Manage pregnancy-related hemorrhoids conservatively whenever possible; topical agents safe in most cases
Complications
- Iron-deficiency anemia from chronic bleeding
- Thrombosis and necrosis
- Prolapse, strangulation
- Incontinence after surgical procedures (rare with modern technique)
- Anal stenosis after extensive hemorrhoidectomy
- Recurrence
PANCE pearls
- Painless bright red bleeding is the hallmark of INTERNAL hemorrhoids — pain suggests fissure, thrombosed external hemorrhoid, or other diagnosis.
- NEVER attribute rectal bleeding to hemorrhoids in patients ≥45 without colonoscopy — colorectal cancer is missed when this rule is violated.
- Thrombosed external hemorrhoid presenting within 48-72 h benefits from EXCISION (not incision) under local anesthesia; after 72 h, conservative management.
- Rubber band ligation is most effective office-based therapy for grade I-II; can be repeated.
- Avoid rubber band ligation in immunocompromised patients (sepsis risk) and patients on anticoagulation.
- Hemorrhoidectomy is painful — multimodal analgesia, sitz baths, stool softeners, and pelvic floor relaxation reduce postoperative discomfort.
- In cirrhotic patients with anorectal bleeding, consider anorectal varices — managed differently (TIPS, endoscopic banding); avoid hemorrhoidectomy.
- Anoscopy is the most useful office tool — DRE cannot evaluate internal hemorrhoids.
References
- ASCRS 2018 — Davis BR et al. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum 2018;61:284-292
- ACG 2014 — Wald A et al. ACG Clinical Guideline: Management of Benign Anorectal Disorders. Am J Gastroenterol 2014;109:1141-1157
Practice Gastrointestinal questions on FirstPassPA
Turn this outline into retention. 5,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Start studying free → Browse all 514 diagnosesEducational use only. This outline is a study aid for PA students and is not medical advice or a substitute for clinical judgment. FirstPassPA is an independent study tool and is not affiliated with, endorsed by, or sponsored by NCCPA or PAEA. PANCE® and PANRE® are registered trademarks of the National Commission on Certification of Physician Assistants; End of Rotation™ is a program of the Physician Assistant Education Association.