Last updated: June 21, 2023

Summarytoggle arrow icon

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.

Etiologytoggle arrow icon

Pathophysiologytoggle arrow icon

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.

Clinical featurestoggle arrow icon

Classificationtoggle arrow icon

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

Diagnosticstoggle arrow icon

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]

Differential diagnosestoggle arrow icon

Always consider the possibility of concurrent colorectal carcinoma.

The differential diagnoses listed here are not exhaustive.

Treatmenttoggle arrow icon

Approach [5][6][7]

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

Medical management of hemorrhoids [5][6][7]

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 for hemorrhoids [5][6][8]

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

Surgery for hemorrhoids [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]

Thrombosed external hemorrhoidtoggle arrow icon


A thrombus within the inferior hemorrhoidal venous plexus distal to the dentate line


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. [15]

Clinical features [6][8][16]

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

Diagnostics [6]

Management [5][6][8]

Surgical excision [12]

Medical management [6][8]

Excision of thrombosed external hemorrhoidstoggle arrow icon

Surgical excision may be considered for patients presenting with acute (< 3–4 days), severely painful thrombosed external hemorrhoids. [8]

Contraindications (relative) [17][18]

Equipment checklist

Procedure [17]

  1. Position the patient in prone or lateral decubitus position.
  2. Retract the buttocks to expose the anal opening.
  3. Prep the skin with an antiseptic solution.
  4. Administer local anesthetic containing epinephrine.
  5. Use forceps to grasp the skin overlying the thrombus.
  6. Make an elliptical incision around the thrombus.
  7. Excise the skin island using the scalpel or dissecting scissors.
  8. Remove the entire thrombus.
  9. Confirm hemostasis.
  10. Apply a gauze dressing.

Use direct pressure, chemical cautery, electrocautery, or a figure-of-eight suture over the bleeding site to control localized bleeding.

Postprocedure checklist [18][19]


  • Bleeding
  • Infection
  • Recurrence [20]

Incision and drainage of a thrombosed external hemorrhoid is more likely to result in local recurrence; excision is the recommended surgical technique. [6][12]

Special patient groupstoggle arrow icon

Hemorrhoids in pregnancy [15][21][22]

  • Hemorrhoids are common in pregnant individuals.
  • Management is typically conservative. [23]

Conservative management


Referencestoggle arrow icon

  1. Standring S. Gray's Anatomy: The Anatomical Basis of Clinical Practice. Elsevier Health Sciences ; 2016
  2. Garden OJ, Bradbury AW, Forsythe JLR, Parks RW. Principles and Practice of Surgery. Elsevier Health Sciences ; 2012
  3. Al Khalloufi K, Laiyemo AO. Management of rectal varices in portal hypertension.. World journal of hepatology. 2015; 7 (30): p.2992-8.doi: 10.4254/wjh.v7.i30.2992 . | Open in Read by QxMD
  4. Robertson M, Thompson AI, Hayes PC. The Management of Bleeding from Anorectal Varices. Current Hepatology Reports. 2017; 16 (4): p.406-415.doi: 10.1007/s11901-017-0382-6 . | Open in Read by QxMD
  5. Wald A, Bharucha AE, Limketkai B, et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021; 116 (10): p.1987-2008.doi: 10.14309/ajg.0000000000001507 . | Open in Read by QxMD
  6. Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018; 61 (3): p.284-292.doi: 10.1097/dcr.0000000000001030 . | Open in Read by QxMD
  7. Mott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician. 2018; 97 (3): p.172-179.
  8. Jacobs D. Hemorrhoids. N Engl J Med. 2014; 371 (10): p.944-951.doi: 10.1056/nejmcp1204188 . | Open in Read by QxMD
  9. Goroll AH, Mulley AG. Primary Care Medicine. Lippincott Williams & Wilkins ; 2009
  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. Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician. 2011; 84 (2): p.204-210.
  16. 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
  17. Shin GH, Toto EL, Schey R. Pregnancy and Postpartum Bowel Changes: Constipation and Fecal Incontinence. Am J Gastroenterol. 2015; 110 (4): p.521-529.doi: 10.1038/ajg.2015.76 . | Open in Read by QxMD
  18. Tol RR, Kleijnen J, Watson AJM, et al. European Society of ColoProctology: guideline for haemorrhoidal disease. Colorectal Disease. 2020; 22 (6): p.650-662.doi: 10.1111/codi.14975 . | Open in Read by QxMD
  19. Story L, Rafique S, Samadi N, Mawdsley J, Singh B, Banerjee A. Lower gastrointestinal bleeding in pregnancy: Differential diagnosis, assessment and management. Obstet Med. 2021; 14 (3): p.129-134.doi: 10.1177/1753495X20948300 . | Open in Read by QxMD
  20. Cengiz TB, Gorgun E. Hemorrhoids: A range of treatments. Cleve Clin J Med. 2019; 86 (9): p.612-620.doi: 10.3949/ccjm.86a.18079 . | Open in Read by QxMD
  21. Ratcliffe SD. Family Medicine Obstetrics E-Book. Elsevier Health Sciences ; 2008
  22. Mirhaidari SJ, Porter JA, Slezak FA. Thrombosed external hemorrhoids in pregnancy: a retrospective review of outcomes. Int J Colorectal Dis. 2016; 31 (8): p.1557-1559.doi: 10.1007/s00384-016-2565-y . | Open in Read by QxMD
  23. Roberts JR. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. Elsevier ; 2018
  24. Reichman EF. Emergency Medicine Procedures, Second Edition. McGraw-Hill Education / Medical ; 2013
  25. Zuber TJ. Hemorrhoidectomy for thrombosed external hemorrhoids. Am Fam Physician. 2002; 65 (8): p.1629-32, 1635-6, 1639.
  26. Walls R, Hockberger R, Gausche-Hill M, Erickson TB, Wilcox SR. Rosen's Emergency Medicine 10th edition- Concepts and Clinical Practice E-Book. Elsevier Health Sciences ; 2022

Icon of a lock3 free articles remaining

You have 3 free member-only articles left this month. Sign up and get unlimited access.
 Evidence-based content, created and peer-reviewed by physicians. Read the disclaimer