HEMORRHOIDS

1..DEFINITION
Hemorrhoids, are swelling and inflammation of veins in the rectum and anus. The ana
tomical term "hemorrhoids" technically refers to "cushions of tissue filled with blood v
essels at the junction of the rectum and the anus".However, the term is popularly use
d to refer to varicosities of the hemorrhoid tissue. Perianal hematoma are sometimes
misdiagnosed and mislabeled as hemorrhoids, when in fact they have different cause
s and treatments.

2..CLASIFICATION
..External hemorrhoids are those that occur outside the anal verge (the distal end of t
he anal canal). Specifically they are varicosities of the veins draining the territory of t
he inferior rectal arteries, which are branches of the internal pudendal artery. They ar
e sometimes painful, and often accompanied by swelling and irritation. Itching, altho
ugh often thought to be a symptom of external hemorrhoids, is more commonly due t
o skin irritation.
External hemorrhoids are prone to thrombosis: if the vein ruptures and/or a blood clo
t develops, the hemorrhoid becomes a thrombosed hemorrhoid. External hemorrhoid
s cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemo
rrhoidal vein can occur. Acute thrombosis is usually related to a specific event, such a
s physical exertion, straining with constipation, a bout of diarrhea, or a change in diet.
These are acute, painful events. Pain results from rapid distension of innervated skin
by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolu
tion of the thrombosis. With this resolution, the stretched anoderm persists as excess
skin or skin tags. External thromboses occasionally erode the overlying skin and caus
e bleeding. Recurrence occurs approximately 40-50% of the time, at the same site (b
ecause the underlying damaged vein remains there). Simply removing the blood clot
and leaving the weakened vein in place, rather than excising the offending vein with
the clot, will predispose the patient to recurrence.

External hemorrhoids can also cause hygiene difficulties, with the excess, redundant
skin left after an acute thrombosis (skin tags) being accountable for these problems.
External hemorrhoidal veins found under the perianal skin obviously cannot cause hy
giene problems; however, excess skin in the perianal area can mechanically interfere
with cleansing.

Internal hemorrhoids cannot cause cutaneous pain, because they are above the dent
ate line and are not innervated by cutaneous nerves. However, they can bleed, prola
pse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, c
ause perianal itching and irritation. Internal hemorrhoids can produce perianal pain b
y prolapsing and causing spasm of the sphincter complex around the hemorrhoids. T
his spasm results in discomfort while the prolapsed hemorrhoids are exposed. This m
uscle discomfort is relieved with reduction.

Internal hemorrhoids can also cause acute pain when incarcerated and strangulated.
Again, the pain is related to the sphincter complex spasm. Strangulation with necrosi
s may cause more deep discomfort. When these catastrophic events occur, the sphin
cter spasm often causes concomitant external thrombosis. External thrombosis cause
s acute cutaneous pain. This consternation of symptoms is referred to as acute hemo
rrhoidal crisis. It usually requires emergent treatment.

Internal hemorrhoids most commonly cause painless bleeding with bowel movements.
The covering epithelium is damaged by the hard bowel movement, and the underlyi
ng veins bleed. With spasm of the sphincter complex elevating pressure, the internal
hemorrhoidal veins can spurt.

Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This
mucus with microscopic stool contents can cause a localized dermatitis, which is calle
d pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending
elements reach the perianal tissue. Hemorrhoids are not the primary offenders.

..Internal hemorrhoids are those that occur inside the rectum. Specifically they are va
ricosities of veins draining the territory of branches of the superior rectal arteries. As
this area lacks pain receptors, internal hemorrhoids are usually not painful and most
people are not aware that they have them. Internal hemorrhoids, however, may blee
d when irritated.

..Untreated internal hemorrhoids can lead to two severe forms of hemorrhoids: prolap
sed and strangulated hemorrhoids:

-Prolapsed hemorrhoids are internal hemorrhoids that are so distended that they are
pushed outside the anus.
-If the anal sphincter muscle goes into spasm and traps a prolapsed hemorrhoid outsi
de the anal opening, the supply of blood is cut off, and the hemorrhoid becomes a str
angulated hemorrhoid

3..CAUSES
Increased straining during bowel movements caused by constipation or diarrhea ma
y lead to hemorrhoids.[6] It is thus a common condition due to constipation caused b
y water retention in women experiencing premenstrual syndrome or menstruation.[ci
tation needed]

Hypertension, particularly portal hypertension, can also cause hemorrhoids because

of the connections between the portal vein and the vena cava which occur in the rect
al wall—known as portocaval anastomoses.[6]

Other factors that can increase the rectal vein pressure resulting in hemorrhoids inclu
de obesity, sitting for long periods of time, and anal intercourse.[6] Poor muscle tone
or poor posture can result in too much pressure on the rectal veins.[citation needed]

During pregnancy, pressure from the fetus on the abdomen and hormonal changes c
ause the hemorrhoidal vessels to enlarge. In addition to the severe pressure during c
hildbirth, these factors contribute to the common occurrence of hemorrhoids among
pregnant women.[6][7][8]

Insufficient liquid can cause a hard stool, or even chronic constipation, which can lea
d to hemorrhoidal radiation.[9] Caffeine, alcohol, nuts, and spicy foods may worsen t
he symptoms

Inflammatory bowel disease and hemorrhoidal problems occur frequently. Unusual he

morrhoidal presentations and findings should alert the clinician to the potential of infl
ammatory bowel disease.
--Ulcerative colitis and Crohn disease are associated with hemorrhoids.
--Pregnancy is associated with many anorectal problems.

Although many patients and clinicians believe that hemorrhoids are caused by chroni
c constipation, prolonged sitting, and vigorous straining, little evidence to support a c
ausative link exists.

Other risk factors historically associated with the development of hemorrhoids includ
e the following:
Pregnancy
Lack of erect posture
Familial tendency
Higher socioeconomic status
Chronic diarrhea
Colon malignancy
Hepatic disease
Obesity
Elevated anal resting pressure
Spinal cord injury
Loss of rectal muscle tone
Rectal surgery
Episiotomy
Anal intercourse
Varicosities caused from portal hypertension are a distinct entity from hemorrhoids

CLINICAL MANIFESTATION

Most symptoms arise from enlarged internal hemorrhoids. Abnormal swelling of the a
nal cushions causes dilatation and engorgement of the arteriovenous plexuses. This l
eads to stretching of the suspensory muscles and eventual prolapse of rectal tissue t
hrough the anal canal. The engorged anal mucosa is easily traumatized, leading to re
ctal bleeding that is typically bright red due to high blood oxygen content within the
arteriovenous anastomoses. Prolapse leads to soiling and mucus discharge (triggerin
g pruritus) and predisposes to incarceration and strangulation.

Most clinicians use the grading system proposed by Banov et al in 1985, which classif
ies internal hemorrhoids by their degree of prolapse into the anal canal. This system
both correlates with symptoms and guides therapeutic approaches.

Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse.
Grade II hemorrhoids may protrude beyond the anal verge with straining or defecatin
g but reduce spontaneously when straining ceases.
Grade III hemorrhoids protrude spontaneously or with straining and require manual re
duction.
Grade IV hemorrhoids chronically prolapse and cannot be reduced. They usually cont
ain both internal and external components and may present with acute thrombosis or
strangulation.

4..PREVENTION
Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber (su
ch as fruits, vegetables and cereals high in fiber), exercising, practicing better postur
e, and reducing bowel movement strain and time. Wearing tight clothing and underw
ear may also contribute to irritation and poor muscle tone in the region and promote
hemorrhoid development.[citation needed]

NDDIC states:

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus d
ecreasing pressure and straining, and to empty bowels as soon as possible after the
urge occurs. Exercise, including walking, and increased fiber in the diet help reduce c
onstipation and straining by producing stools that are softer and easier to pass.[10]

Women who notice they have painful stools around the time of menstruation would b
e well-advised to begin taking extra dietary fiber and fluids a couple of days prior to t
hat time.[citation needed]

Fluids emitted by the intestinal tract may contain irritants that may increase the fissu
res associated with hemorrhoids. Washing the anus with cool water and soap may re
duce the swelling and increase blood supply for quicker healing and may remove irrit
ating fluid.[citation needed]

Kegel exercises for the pelvic floor may also prove helpful.[citation needed]

Many people do not get a sufficient supply of dietary fiber (20 to 25 grams daily), and
small changes in a person's daily diet can help tremendously in both prevention and t
reatment of hemorrhoids.[citation needed]

[edit] Use of squat toilets

Based on their very low incidence in the underdeveloped world, where most people s
quat for defecation, hemorrhoids have been attributed to the use of the "sitting" toile
t.[11][12] Dr. Berko Sikirov published a study in 1987 testing this hypothesis by havin
g hemorrhoid sufferers convert to squat toilets.[13] Eighteen of the 20 patients were
completely relieved of their symptoms (pain and bleeding) with no recurrence, even
30 months after completion of the study. This chart summarizes the results. This stud
y was undertaken in a very small number of people, when compared to the numbers i
nvolved in recognized high-quality trials. Therefore, the results, while highly suggesti
ve, cannot be assumed to provide a firm conclusion.

5..EXAMINATION nursing management

Endoscopic image of internal hemorrhoids seen on retroflexion of the flexible sigmoid

oscope at the ano-rectal junctionAfter visual examination of the anus and surroundin
g area for external or prolapsed hemorrhoids, a doctor may conduct a digital examin
ation. In addition to probing for hemorrhoidal bulges, a doctor may also look for indic
ations of rectal tumor or polyp, enlarged prostate and abscesses.

Visual confirmation of hemorrhoids can be done by doing an anoscopy, using a medic

al device called an anoscope. This device is basically a hollow tube with a light attach
ed at one end that allows the doctor to see the internal hemorrhoids, as well as polyp
s in the rectum.

If warranted, more detailed examinations, such as sigmoidoscopy and colonoscopy ca

n be performed. In sigmoidoscopy, the last 60 cm of the colon and rectum are exami
ned whereas in colonoscopy the entire large bowel (colon) is examined.

A pathologist will look for dilated vascular spaces which exhibit thrombosis and recan
alization

6..TREATMENTS medical management

Treatments for hemorrhoids vary in their cost, risk, and effectiveness. Different cultur
es and individuals approach treatment differently. Some of the treatments used are li
sted here in increasing order of intrusiveness and cost.
---Home treatments
Temporary relief from symptoms can be provided by:

Hydrotherapy with a bathtub, bidet, or extendable shower head. Especially in the cas
e of an external hemorrhoids with a visible lump of small size, the condition can be i
mproved with warm bath causing the vessels around the rectal region to be relaxed.
[citation needed]
Cold compress.[citation needed]
Topical analgesic (pain reliever), such as cinchocaine or pramocaine.
Systemic (pill-form) analgesic (pain reliever).
Topical vasoconstrictor such as phenylephrine.
Topical moisturizer.
Topical astringent, such as witch hazel
In case of bleeding piles, the use of onion has been found useful. About 30 grams of r
aw onion, after washing with water, mixed with same amount of sugar should be take
n twice daily.[citation needed]
Tea Tree Oil
Topical medicines may be delivered as an ointment or suppository. Some hemorrhoi
d-specific medications contain a mixture of multiple ingredients, such as Preparation
H, Proctosedyl, and Faktu.

---Surgical and non-medicinal treatments

Rubber band ligation, sometimes called Baron ligation. Elastic bands are applied onto
an internal hemorrhoid to cut off its blood supply.[14] Within several days, the wither
ed hemorrhoid, is sloughed off during normal bowel movement.
Hemorrhoidolysis, desiccation of the hemorrhoid by electrical current.
Sclerotherapy, sclerosant or another hardening agent is injected into hemorrhoids. Th
is causes the vein walls to collapse and the hemorrhoids to shrivel up.
Cryosurgery, a frozen tip of a cryoprobe is used to destroy hemorrhoidal tissues.[15]
Rarely used anymore because of side effects.
Hemorrhoidectomy, a surgical excision of the hemorrhoid. Has possible correlation wi
th incontinence issues later in life; in addition, many patients complain that pain duri
ng recovery is severe. For this reason it is often now recommended only for severe (g
rade IV) hemorrhoids.
Transanal Hemorrhoidal Dearterialization (THD-HP) is a minimally invasive treatment
for hemorrhoids and hemorrhoidal prolapse [16][17][18]. THD uses an ultrasound dop
pler to accurately locate the arterial blood inflow. With simple suture, these arteries a
re “tied off” and the prolapsed tissue is sutured back to anatomical position without e
xcision of tissue. THD is performed above the nerve bundles, or dentate line. Because
of this, there is very little pain. THD is typically performed in an out-patient setting an
d return to normal activities is within a few days.
Stapled hemorrhoidectomy, a resection of a soft tissue proximal to the dentate line,
which disrupts the blood flow to the hemorrhoids. It is generally less painful than com
plete removal of hemorrhoids and also allows for faster recovery times. It is meant fo
r hemorrhoids that fall out or bleed and is not helpful for painful outside conditions.
Doppler guided hemorrhoidal artery ligation or better known as THD [Transanal hemo
rrhoidal Dearterialization], which cuts the artery that delivers blood to the hemorrhoi
d. It is the best treatment for bleeding piles, as the bleeding stops immediately.[19]

---Natural treatments
Eating fiber-rich diets, as well as drinking lots of water, help to create a softer stool th
at is easier to pass, to lessen the irritation of existing hemorrhoids.[20]
Using the squatting position for bowel movements.[13]
Dietary supplements can help treat and prevent many complications of hemorrhoids,
and natural botanicals such as Butchers Broom, Horse-chestnut, Hem-eez and bioflav
onoids can be an effective addition to hemorrhoid treatment.[21]
Butcher's Broom extract, or Ruscus aculeatus, contains ruscogenins that have anti-inf
lammatory and vasoconstrictor effects that help tighten and strengthen veins. Butch
er's Broom has traditionally been used to treat venous problems including hemorrhoi
ds and varicose veins.

Horse-chestnut extract, or Aesculus hippocastanum, contains a saponin known as aes

cin, that has anti-inflammatory, anti-edema, and venotonic actions. Aescin improves t
one in vein walls, thereby strengthening the support structure of the vein. Double bli
nd studies have shown that supplementation with horse-chestnut helps relieve the pa
in and swelling associated with chronic venous insufficiency.

In some cases, hemorrhoids must be treated endoscopically or surgically. These met

hods are used to shrink and destroy the hemorrhoidal tissue. The doctor will perform
the procedure during an office or hospital visit.

A number of methods may be used to remove or reduce the size of internal hemorrho
ids. These techniques include

Rubber band ligation. A rubber band is placed around the base of the hemorrhoid insi
de the rectum. The band cuts off circulation, and the hemorrhoid withers away within
a few days.

Sclerotherapy. A chemical solution is injected around the blood vessel to shrink the h
emorrhoid.

Infrared coagulation. A special device is used to burn hemorrhoidal tissue.

Hemorrhoidectomy. Occasionally, extensive or severe internal or external hemorrhoi

ds may require removal by surgery known as hemorrhoidectomy.

7..HEALTH EDUCATION

Ask patient to take baths several times a day in plain, warm water for about 10 minutes
application of a hemorrhoidal cream or suppository to the affected area for a limited t
ime
Preventing the recurrence of hemorrhoids will require relieving the pressure and strai
ning of constipation. Doctors will often recommend increasing fiber and fluids in the d
iet. Eating the right amount of fiber and drinking six to eight glasses of fluid—not alco
hol—result in softer, bulkier stools. A softer stool makes emptying the bowels easier a
nd lessens the pressure on hemorrhoids caused by straining. Eliminating straining als
o helps prevent the hemorrhoids from protruding.

Good sources of fiber are fruits, vegetables, and whole grains. In addition, doctors ma
y suggest a bulk stool softener or a fiber supplement such as psyllium (Metamucil) or
methylcellulose (Citrucel).

The best way to prevent hemorrhoids is to keep stools soft so they pass easily, thus d
ecreasing pressure and straining, and to empty bowels as soon as possible after the
urge occurs. Exercise, including walking, and increased fiber in the diet help reduce c
onstipation and straining by producing stools that are softer and easier to pass.

8..Diseases with similar symptoms

Symptoms associated with rectal cancer, anal fissure, anal abscess, anal fistula, peria
nal hematoma, and other diseases may be similar to those produced by hemorrhoids
and may be reduced by the topical analgesic methods described above. For this reas
on, it is a good idea to consult with a physician when these symptoms are encountere
d, particularly for the first time, and periodically should the problem continue. In the
US, colonoscopy is recommended as a general diagnostic for those over age 50 (40 w
ith family history of bowel cancers

Hemorrhoids may result from straining to move stool. Other contributing factors inclu
de pregnancy, aging, chronic constipation or diarrhea, and anal intercourse.

Hemorrhoids are either inside the anus—internal—or under the skin around the anus
—external.

9..What are the symptoms of hemorrhoids?

Many anorectal problems, including fissures, fistulae, abscesses, or irritation and itchi
ng, also called pruritus ani, have similar symptoms and are incorrectly referred to as
hemorrhoids.

Hemorrhoids usually are not dangerous or life threatening. In most cases, hemorrhoid
al symptoms will go away within a few days.

Although many people have hemorrhoids, not all experience symptoms. The most co
mmon symptom of internal hemorrhoids is bright red blood covering the stool, on toil
et paper, or in the toilet bowl. However, an internal hemorrhoid may protrude throug
h the anus outside the body, becoming irritated and painful. This is known as a protru
ding hemorrhoid.

Symptoms of external hemorrhoids may include painful swelling or a hard lump arou
nd the anus that results when a blood clot forms. This condition is known as a thromb
osed external hemorrhoid.

In addition, excessive straining, rubbing, or cleaning around the anus may cause irrit
ation with bleeding and/or itching, which may produce a vicious cycle of symptoms. D
raining mucus may also cause itching.

10..How common are hemorrhoids?

Hemorrhoids are common in both men and women. About half of the population has
hemorrhoids by age 50. Hemorrhoids are also common among pregnant women. The
pressure of the fetus on the abdomen, as well as hormonal changes, cause the hemo
rrhoidal vessels to enlarge. These vessels are also placed under severe pressure duri
ng childbirth. For most women, however, hemorrhoids caused by pregnancy are a te
mporary problem.

11..How are hemorrhoids diagnosed?

A thorough evaluation and proper diagnosis by the doctor is important any time blee
ding from the rectum or blood in the stool occurs. Bleeding may also be a symptom o
f other digestive diseases, including colorectal cancer.

The doctor will examine the anus and rectum to look for swollen blood vessels that in
dicate hemorrhoids and will also perform a digital rectal exam with a gloved, lubricat
ed finger to feel for abnormalities.

Closer evaluation of the rectum for hemorrhoids requires an exam with an anoscope,
a hollow, lighted tube useful for viewing internal hemorrhoids, or a proctoscope, usef
ul for more completely examining the entire rectum.

To rule out other causes of gastrointestinal bleeding, the doctor may examine the rec
tum and lower colon, or sigmoid, with sigmoidoscopy or the entire colon with colonos
copy. Sigmoidoscopy and colonoscopy are diagnostic procedures that also involve th
e use of lighted, flexible tubes inserted through the rectum.

12..Conclusion
Hemorrhoids are present in healthy individuals. Up to one third of the 10 million peop
le in the United States with hemorrhoids seek medical treatment, resulting in 1.5 milli
on related prescriptions per year.

The number of hemorrhoidectomies performed in hospitals is declining. A peak of 11

7 hemorrhoidectomies per 100,000 people was reached in 1974; this rate declined to
37 hemorrhoidectomies per 100,000 people in 1987. Obviously, outpatient and office
treatment of hemorrhoids account for some of this decline.

Hemorrhoids plague all age groups, although they occur most often in individuals age
d 46-65 years

13.. Pathophysiology
Hemorrhoidal venous cushions are a normal part of the human anorectum and arise
from subepithelial connective tissue within the anal canal.

Present in utero, these cushions surround and support distal anastomoses between t
he superior rectal arteries and the superior, middle, and inferior rectal veins. They als
o contain a subepithelial smooth muscle layer, contributing to the bulk of the cushion
s. Normal hemorrhoidal tissue accounts for approximately 15-20% of resting anal pre
ssure and provides important sensory information, enabling the differentiation betwe
en solid, liquid, and gas.

Most people contain 3 of these cushions. Although classically described as lying in th

e right posterior (most common), right anterior, and left lateral positions, this combin
ation is found in only 19% of patients. Hemorrhoids can be found at any position withi
n the rectum.

Hemorrhoids are classified by their anatomic origin within the anal canal and by their
position relative to the dentate line.

Internal hemorrhoids develop above the dentate line from embryonic endoderm. The
y are covered by the simple columnar epithelium of anal mucosa and lack somatic se
nsory innervation and are therefore painless.
External hemorrhoids develop from ectoderm and arise distal to the dentate line. The
y are covered by stratified squamous epithelium and receive somatic sensory innerva
tion from the inferior rectal nerve rendering them painful when irritated.

Internal hemorrhoids drain through the superior rectal vein into the portal system.
External hemorrhoids drain through the inferior rectal vein into the inferior vena cava.
Rich anastomoses exist between these 2 and the middle rectal vein, connecting the p
ortal and systemic circulations.

Relevant Anatomy
Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg, arterioles, v
enules, arteriolar-venular connections), smooth muscle (eg, Treitz muscle), and conn
ective tissue lined by the normal epithelium of the anal canal. Hemorrhoids are prese
nt in utero and persist through normal adult life. Evidence indicates that hemorrhoida
l bleeding is arterial and not venous. This evidence is supported by the bright red col
or and arterial pH of the blood.

Hemorrhoids are categorized into internal and external hemorrhoids. These categorie
s are anatomically separated by the dentate (pectinate) line. External hemorrhoids ar
e hemorrhoids covered by squamous epithelium, whereas internal hemorrhoids are li
ned with columnar epithelium. Similarly, external hemorrhoids are innervated by cuta
neous nerves that supply the perianal area. These nerves include the pudendal nerve
and the sacral plexus. Internal hemorrhoids are not supplied by somatic sensory nerv
es and therefore cannot cause pain. At the level of the dentate line, internal hemorrh
oids are anchored to the underlying muscle by the mucosal suspensory ligament.

Internal hemorrhoids have 3 main cushions, which are situated in the left lateral, righ
t posterior, and right anterior areas of the anal canal. Minor tufts can be found betwe
en the major cushions.
Hemorrhoids are one of the most common causes of anal pathology. Subsequently, h
emorrhoids are blamed for virtually any anorectal complaint by patients and medical
professionals alike. Confusion often arises because the term "hemorrhoid" has been u
sed to refer to both normal anatomical structures and pathological structures. In the
context of this article, "hemorrhoids" refers to the pathological presentation of hemor
rhoidal venous cushions.

External hemorrhoidal veins are found circumferentially under the anoderm; they can
cause trouble anywhere around the circumference of the anus.

Contraindications
Care must be taken to ensure that symptoms are not caused by other perianal condit
ions (eg, fissure, fistula, infectious disease, inflammatory bowel disease, parasites). O
bviously, treating hemorrhoids will not help these problems. Frequently, a thorough h
istory can eliminate the above conditions.

Inflammatory bowel diseases (eg, ulcerative colitis, Crohn disease) need to be ruled o
ut as the cause of symptoms. Human immunodeficiency virus (HIV) infection and oth
er immunosuppressive diseases also can alter treatment plans.

Introduction
Background

Hemorrhoidal venous cushions are normal structures of the anorectum and are unive
rsally present unless a prior intervention has taken place. Because of their rich vascul
ar supply, highly sensitive location, and tendency to engorge and prolapse, they are c
ommon causes of anal pathology.1 Symptoms can range from mildly bothersome, su
ch as pruritus, to quite concerning, such as rectal bleeding, and while it is a common
condition diagnosed in clinical practice, many patients are too embarrassed to ever s
eek treatment. Consequently, the true prevalence of pathologic hemorrhoids is not k
nown.2

Even though hemorrhoids are responsible for a large portion of anorectal complaints,
it is important to rule out more serious conditions, such as other causes of GI bleedin
g, before reflexively attributing symptoms to hemorrhoids.3
Frequency
United States
Prevalence of symptomatic hemorrhoids is estimated at 4.4% in the general populati
on.

Race
Patients presenting with hemorrhoidal disease are more frequently Caucasian, from h
igher socioeconomic status, and from rural areas.

Sex
No predilection is known, although men are more likely to seek treatment. However,
pregnancy causes physiologic changes that predispose women to developing sympto
matic hemorrhoids. As the gravid uterus expands, it compresses the inferior vena cav
a, causing decreased venous return and distal engorgement.

Age
External hemorrhoids occur more commonly in young and middle-aged adults than in
older adults. The prevalence of hemorrhoids increases with age, with a peak in perso
ns aged 45-65 years.

Clinical
History
The most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or p
rolapse. However, these symptoms are extremely nonspecific and may be seen in a n
umber of anorectal diseases. The physician must therefore rely on a thorough history
to help narrow the differential and must perform an adequate physical examination (i
ncluding anoscopy when indicated) to confirm the diagnosis.

An adequate history should include the onset and duration of symptoms. In addition t
o characterizing any pain, bleeding, protrusion, or change in bowel habits, special att
ention should be placed on the patient's coagulation history and immune status.
Bleeding is the most common presenting symptom. Blood is usually bright red and m
ay drip, squirt into the toilet bowl, or appear as streaks on the toilet paper. The physi
cian should inquire about the quantity, color, and timing of any rectal bleeding. Darke
r blood or blood mixed with stool should raise suspicion of a more proximal cause of
bleeding.
A patient with a thrombosed external hemorrhoid may present with complaints of an
acutely painful mass at the rectum (see Media file 1). Pain truly caused by hemorrhoi
ds usually arises only with acute thrombus formation. This pain peaks at 48-72 hours
and begins to decline by the fourth day as the thrombus organizes. New-onset anal p
ain in the absence of a thrombosed hemorrhoid should prompt investigation for an alt
ernate cause, such as an intersphincteric abscess or anal fissure. As many as 20% of
patients with hemorrhoids will have concomitant anal fissures.

Thrombosed hemorrhoid

Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of clot.
The presence, timing, and reducibility of prolapse, when present, will help classify the
grade of internal hemorrhoids and guide the therapeutic approach.
Grade I internal hemorrhoids are usually asymptomatic but, at times, may cause mini
mal bleeding.
Grades II, III, or IV internal hemorrhoids usually present with painless bleeding but als
o may present with complaints of a dull aching pain, pruritus, or other symptoms due
to prolapse.
Familial predisposition, diet, history of constipation or diarrhea, and history of prolong
ed sitting or heavy lifting are also relevant, as are weight loss, abdominal pain, or any
change in appetite or bowel habits. Presence of pruritus or any discharge should also
be noted.

Physical
In addition to the general physical examination, physicians should also perform visual
inspection of the rectum, digital rectal examination, and anoscopy or proctosigmoido
scopy when appropriate.

The preferred position for the digital rectal examination is the left lateral decubitus wi
th the patient's knees flexed toward the chest. Topical anesthetics (eg, 20% benzocai
ne or 5% lidocaine ointment) may help to reduce any discomfort caused by examinati
on.

External findings important to note include any of the following:

Redundant tissue
Skin tags from old thrombosed external hemorrhoids
Fissures
Fistulas
Signs of infection or abscess formation
Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass
During the digital rectal examination, assess for any masses, tenderness, mucoid disc
harge or blood, and rectal tone. Internal hemorrhoids are usually not palpable unless
thrombosed.
Current guidelines from most gastrointestinal and surgical societies advocate anosco
py and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonosc
opy should be considered in the evaluation of any rectal bleeding that is not typical o
f hemorrhoids such as in the presence of strong risk factors for colonic malignancy or
in the setting of rectal bleeding with a negative anorectal examination.