Hemorrhoids: A range of treatments

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Release date: September 1, 2019
Expiration date: August 31, 2020
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Hemorrhoids are a common reason for office visits. Each patient is unique, and with a range of treatments available, treatment can be individualized. This article reviews the diagnosis and decision-making process for individualized treatment.


  • Hemorrhoids account for more than 3.5 million office visits annually.
  • Most patients present with painless rectal bleeding, but this can also be a sign of colorectal cancer, which needs to be ruled out.
  • Fiber supplements along with dietary and lifestyle changes are recommended for all patients with hemorrhoids regardless of symptom severity.
  • Hemorrhoids are graded on a scale of I (least severe) through IV (most severe). Office-based treatments are effective for grades I, II, and some grade III hemorrhoids. Surgical excision is the standard for high-grade hemorrhoids.



Aspects of modern life that may promote hemorrhoids include increased consumption of processed foods, a sedentary lifestyle, and using cell phones while defecating, which translates to much more time spent on the toilet.

Hemorrhoids accounted for more than 3.5 million US outpatient visits in 2010, and they were the third leading cause of hospital admissions related to gastrointestinal disease.1

Here, we review the process for diagnosing and grading hemorrhoids, as well as for selecting the appropriate medical or surgical treatment based on the most recent clinical evidence.


Hemorrhoids are the distal prolapse of the arteriovenous bundle, muscle fibers, and surrounding connective tissue as an envelope below the dentate line in the anal canal. They usually present with painless rectal bleeding.2

The diagnosis of hemorrhoids relies on the history and physical examination rather than on laboratory testing or imaging studies. Typically, the presenting symptom is painless rectal bleeding associated with bowel movements, usually appearing as bright red blood on the toilet paper or coating the stool. Severe itching and anal discomfort are also common, especially with chronic hemorrhoids.

Detailed patient history

A detailed patient history is important. It should include the extent, severity, and duration of symptoms, frequency of bowel movements, associated symptoms (eg, constipation, fecal incontinence), daily dietary habits, and details of bowel movements (eg, time spent during each bowel movement and concomitant cell phone use).3

Regarding bowel habits, some patients experience lifelong constipation or diarrhea. Therefore, what a patient considers a normal bowel habit may not be normal and should be investigated.4 Also, it is important to exclude external thrombosed hemorrhoids, anal fissure, anal abscess, and Crohn disease.5

Physical examination

A digital rectal examination is the second step. During the examination, look for skin tags, sphincter tone, perianal hygiene, and synchronous anal lesions.3 Of note, the Valsalva maneuver can be performed during the digital rectal examination.

Red flags for colorectal cancer on the digital rectal examination include a mass with or without presence of hemorrhoidal sacs and a bleeding source above the level of internal hemorrhoids.

Figure 1. Patient with Crohn disease. Note the fistula orifices and the skin tag.

Figure 1. Patient with Crohn disease. Note the fistula orifices and the skin tag.

Patients with recurrent abscesses, fistulas, or skin tags (especially cauliflower-type skin tags) should be investigated for Crohn disease (Figure 1).


Since rectal bleeding can be a sign of several diseases, including colorectal cancer, it is important to review any previous endoscopic results. Patients at high risk of colon cancer should undergo rigid proctoscopy, flexible sigmoidoscopy, or colonoscopy.3,4 In our practice, we recommend endoscopic evaluation for patients over age 40 with rectal bleeding, especially if they have a family history of colorectal cancer.

External or internal (grades I–IV)

Hemorrhoids can be categorized as either external or internal.

External hemorrhoids are distinguished by their outer covering with perianal skin and anoderm and their location inferior to the dentate line. They are painful if the hemorrhoidal sac is occluded by a thrombotic clot.

Internal hemorrhoids are above the dentate line and covered with rectal columnar and transitional mucosa. They are further graded on a 4-point scale3:

  • Grade I—Visible hemorrhoids that do not prolapse
  • Grade II—Hemorrhoids that prolapse during the Valsalva maneuver but spontaneously reduce
  • Grade III—Hemorrhoids that prolapse during the Valsalva maneuver and need manual reduction
  • Grade IV—Nonreducible hemorrhoids.


In choosing the treatment for hemorrhoids, one should consider the disease grade and severity, its impact on the quality of life, the degree of pain it causes, the patient’s likelihood of adhering to treatment, and the patient’s personal preference.

Regardless of severity, treatment almost always starts with a high-fiber diet and other lifestyle modifications that include bowel movement behaviors. This requires practitioners to spend significant time on patient education regardless of the type or the severity of the disease.

Treatments can be grouped in 3 categories: conservative, office-based, and surgical. Practitioners should thoroughly discuss the options with the patient, emphasizing the pros and cons of each.


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