Hemorrhoids are swollen cushions of blood vessels in the anal canal, linked to straining, constipation, pregnancy and long sitting. Internal hemorrhoids usually bleed painlessly, while a clot in an external hemorrhoid causes sudden severe pain.
Key symptoms
- Painless bright red blood on the toilet paper or in the bowl
- Itching or irritation around the anus
- A lump that bulges out with bowel movements
- Sudden painful lump at the anal edge (thrombosed external hemorrhoid)
What you find on exam
- Look at the anus for external hemorrhoids, fissures or skin tags
- Digital rectal exam to feel for masses
- Anoscopy to see and grade internal hemorrhoids
- Vital signs and pallor if bleeding is heavy
Tests
- Usually diagnosed by exam and anoscopy
- Blood count if bleeding is heavy or ongoing
- Colonoscopy for age 45 or older, anemia, change in bowel habits or family history of colon cancer
Treatment basics
- More fiber and fluids; avoid straining and long sitting on the toilet
- Sitz baths and short use of topical creams such as hydrocortisone
- Rubber band ligation for internal hemorrhoids that keep bleeding
- Excision of a thrombosed external hemorrhoid within about 72 hours of onset
- Surgery (hemorrhoidectomy) for large or refractory hemorrhoids
Red flags
- Heavy bleeding, dizziness or anemia
- Change in bowel habits, weight loss, or bleeding after age 45
- Severe pain with fever or a hard, dark prolapsed lump
Practice it in Making Synapses
Making Synapses cases
Related guides
Sources: NCCPA PANCE Content Blueprint; NBOME COMLEX-USA clinical presentations; AAMC Core Entrustable Professional Activities (Core EPAs). Written by Making Synapses. Making Synapses is not affiliated with these organizations.