Last updated: February 23, 2022

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Hemorrhoids are dilated submucosal vascular cushions within the anal canal that can be asymptomatic or manifest as painless perianal masses, pruritus, or intermittent scant hematochezia (bright red blood per rectum, typically at the end of defecation). Excessive straining during defecation or intraabdominal pressure (e.g., due to constipation, pregnancy, or prolonged periods sitting) increase the likelihood of developing hemorrhoids. Based on their anatomical location, hemorrhoids are internal (above the dentate line), external (below the dentate line), or mixed. Internal hemorrhoids are classified into four grades according to the extent of prolapse. The diagnosis is primarily clinical, based on a thorough history and examination that includes a digital rectal examination and anoscopy. Further investigation with proctoscopy, sigmoidoscopy, or colonoscopy may be required to rule out differential diagnoses of hemorrhoids, including colorectal cancer. All patients with symptomatic hemorrhoids should be counseled on lifestyle modifications (e.g., increased fiber and fluid intake, regular physical activity) to reduce straining during defecation. Medical management also includes stool softeners and short-term use of topical medications (e.g., anesthetics, corticosteroids, or vasoconstrictors) for symptomatic relief. Hemorrhoids refractory to medical management and larger (grades III and IV) internal hemorrhoids typically require procedures such as rubber band ligation, sclerotherapy, and infrared coagulation, or surgery. Thrombosed external hemorrhoids manifest with acute pain and a tender bluish-purple perianal nodule. Surgical excision of the thrombosed hemorrhoid may be beneficial in patients who present within 3–4 days of symptom onset. Those who present later should be managed conservatively.

Anatomy of the anal canal

Characteristics of the anal canal above and below the dentate line [3][4]
Above the dentate line Below the dentate line
Embryological origin

Arterial supply

Venous drainage
Lymphatic drainage
Clinical relevance

Internal vs. external hemorrhoids

Hemorrhoids are classified as internal , external , or mixed .

Hemorrhoids are not varicose veins (dilated, tortuous veins). Anorectal varices occur, e.g., as a result of portal hypertension. The terms anorectal varices and hemorrhoids are often used interchangeably, but this is incorrect.

Internal hemorrhoids are graded according to extent of prolapse. There is no widely used classification system for external hemorrhoids.

Grading of internal hemorrhoids [5]
Grade Palpation findings
I Hemorrhoids bleed but do not prolapse.
II Prolapse when straining, but spontaneously reduce at rest
III Prolapse when straining; only reducible manually
IV Irreducible prolapse; may be strangulated and thrombosed with possible ulceration

Approach [5][6][7]

Hemorrhoids are a clinical diagnosis.

Physical examination [5][7][8]

Anoscopy [6][8]

  • Insertion of an anoscope to directly visualize the anus and distal rectum [9]
  • Perform in all patients with suspected hemorrhoids. [7][8]
  • May show hemorrhoids or differential diagnoses, e.g., anal carcinoma or fissure

Further studies [6][8][10]

Always consider the possibility of concurrent colorectal carcinoma.

The differential diagnoses listed here are not exhaustive.

Approach [5][6][7]

Hemorrhoids should only be treated in symptomatic patients. [6]

Medical management [5][6][7]

  • Indications: all patients with hemorrhoids
  • Interventions to reduce anorectal pressure and straining
    • Lifestyle modifications [5]
      • High fiber diet (20–30 g/day)
      • Increased fluid intake
      • Avoidance of fatty foods
      • Regular physical activity
      • Avoidance of excessive straining [11]
      • Limiting the amount of time spent on the toilet
    • Short-term (up to 1 week) use of stool softeners (e.g., docusate) or laxatives (e.g., polyethylene glycol 3350) as needed [5]
  • Interventions to alleviate symptoms (e.g., pain, pruritus)

Conservative management is often the only intervention required for grade I–II internal hemorrhoids and external hemorrhoids.

Long-term use of topical medications for hemorrhoids can lead to sensitization and localized reactions and should be avoided. [6]

Office-based procedures [5][6][8]

Sclerotherapy may be preferable in patients with actively bleeding hemorrhoids who are on anticoagulants. [5]

Surgery [6][7]

Pain is common after surgical treatment of hemorrhoids. Consider multimodal analgesia including local anesthesia and use of topical medications (e.g., diltiazem or nitroglycerin ointment) to reduce the need for opioid analgesics. [6]

Perianal sepsis can occur after surgical or office-based interventions for hemorrhoids and may manifest with worsening pain, fever, or dysuria. [6]


A thrombosed external hemorrhoid is a complication of external hemorrhoids and is caused by localized thrombosis of an inferior hemorrhoidal venous plexus.


Stasis of blood within the external hemorrhoidthrombus formationinflammation and distention of the overlying perianal skinsevere pain

Clinical features [6][8][15]

  • Acute onset of severe perianal pain
  • Painful perianal mass that may ulcerate and bleed
  • Painful defecation

Diagnostics [6]

Treatment [6][8][15]

External hemorrhoids are located distal to the dentate (pectinate) line and are drained by the inferior hemorrhoidal (rectal) plexus. External hemorrhoid thrombosis occurs if a clot forms in the inferior hemorrhoidal plexus. [16]

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  10. Clinical Practice Committee, American Gastroenterological Association. American Gastroenterological Association medical position statement: Diagnosis and treatment of hemorrhoids. Gastroenterology. 2004; 126 (5): p.1461-1462. doi: 10.1053/j.gastro.2004.03.001 . | Open in Read by QxMD
  11. Modi RM, Hinton A, Pinkhas D, et al. Implementation of a Defecation Posture Modification Device: Impact on Bowel Movement Patterns in Healthy Subjects. J Clin Gastroenterol. 2019; 53 (3): p.216-219. doi: 10.1097/MCG.0000000000001143 . | Open in Read by QxMD
  12. Migaly J, Sun Z. Review of Hemorrhoid Disease: Presentation and Management. Clin Colon Rectal Surg. 2016; 29 (01): p.022-029. doi: 10.1055/s-0035-1568144 . | Open in Read by QxMD
  13. Hardy A, Chan CLH, Cohen CRG. The Surgical Management of Haemorrhoids – A Review. Dig Surg. 2005; 22 (1-2): p.26-33. doi: 10.1159/000085343 . | Open in Read by QxMD
  14. Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist’s view. World J Gastroenterol. 2015; 21 (31): p.9245-52. doi: 10.3748/wjg.v21.i31.9245 . | Open in Read by QxMD
  15. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014; 109 (8): p.1141-57; (Quiz) 1058. doi: 10.1038/ajg.2014.190 . | Open in Read by QxMD
  16. Mounsey AL, Halladay J, Sadiq TS . Hemorrhoids. Am Fam Physician. 2011; 84 (2): p.204-210.

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