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.
Try two board-style Hemorrhoids questions
Real questions from the FirstPassPA bank, with the full explanation. Pick an answer — no signup, no email.
Question 1GastrointestinalMedium
A 52-year-old woman reports several months of painless, bright red blood coating the toilet paper after most bowel movements. She eats a low-fiber diet and strains frequently with hard stools. She denies weight loss, abdominal pain, or change in stool caliber. Anoscopy reveals grade II internal hemorrhoids, and a colonoscopy performed last month was normal. If her bleeding continues untreated, which of the following complications is she at greatest risk of developing?
AAcute hemorrhagic shock
BStrangulated prolapse
CThrombosed hemorrhoid
DIron-deficiency anemia
Reveal answer & full explanation
Correct answer: D — Iron-deficiency anemia
AAcute hemorrhagic shock
BStrangulated prolapse
CThrombosed hemorrhoid
DIron-deficiency anemia✓
Why Iron-deficiency anemia is correct
Chronic low-grade bleeding from internal hemorrhoids is the most common complication, producing slow occult blood loss that gradually depletes iron stores.
Over months this can lower hemoglobin and produce a microcytic, hypochromic (low-MCV) anemia; checking a CBC is appropriate, and her recent normal colonoscopy has already excluded a proximal or malignant source of bleeding.
Why the others are wrong
Acute hemorrhagic shock — hemorrhoidal bleeding is low-volume outlet-type bleeding that streaks the paper; massive hemorrhage severe enough to cause shock is rare and would present abruptly rather than as months of painless spotting.
Strangulated prolapse — requires hemorrhoids that prolapse and cannot be reduced (grade IV); hers are grade II and reduce spontaneously after defecation.
Thrombosed hemorrhoid — acute clot formation causes sudden severe anal pain and a tender bluish lump, most often in an external hemorrhoid; it is unrelated to how long painless internal bleeding continues.
Question 2GastrointestinalEasy
A 52-year-old man presents with intermittent painless bright red blood on the toilet paper after bowel movements for the past 3 months. He reports hard, infrequent stools and often spends 15-20 minutes straining on the toilet while reading. He eats a diet heavy in processed foods and drinks little water. He has a BMI of 27 and works a desk job. Anoscopy reveals nonprolapsing internal hemorrhoids. Which of the following is the strongest risk factor for this condition?
ASedentary desk occupation
BMale sex of the patient
COverweight body habitus
DStraining at hard stool
Reveal answer & full explanation
Correct answer: D — Straining at hard stool
ASedentary desk occupation
BMale sex of the patient
COverweight body habitus
DStraining at hard stool✓
Why Straining at hard stool is correct
Repeated straining against hard stool raises intra-abdominal pressure, engorging the anal vascular cushions and weakening their supporting connective tissue (Treitz muscle/Parks ligament), allowing downward displacement and prolapse.
Chronic constipation with straining is the single most consistently implicated and modifiable driver of hemorrhoid development, which is why first-line therapy targets it directly: fiber 25-35 g/day, hydration, bulk-forming laxatives, and avoiding prolonged toilet sitting.
This patient's hard infrequent stools, low-fiber/low-water diet, and prolonged straining all converge on this mechanism.
Why the others are wrong
Sedentary desk occupation - prolonged sitting is a contributory factor, but it acts largely by promoting constipation and reduced bowel motility, so it is downstream and weaker than the straining itself.
Overweight body habitus - a real but weaker contributing risk factor; a BMI of 27 is overweight (not obese) and is a minor influence compared with the daily straining driving his disease.
Male sex of the patient - hemorrhoids have an essentially equal sex distribution, so sex is not a meaningful risk factor; pregnancy (not male sex) is the notable sex-specific contributor, and it raises risk in women.
🔒 Free preview limit reached
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, 6,500+ board-style questions, flashcards, and an AI tutor. Your 7-day free trial includes everything, and there's no credit card required.
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
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
Goligher classification of internal hemorrhoids — grade directs management.
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
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. 6,500+ board-style questions with an AI tutor that explains every answer — free to start, no card required.
Educational 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.