How to Cite This Chapter: Yoon HM, Eskicioglu C, Bartnik W. Hemorrhoids. McMaster Textbook of Internal Medicine. Kraków: Medycyna Praktyczna. https://empendium.com/mcmtextbook/chapter/B31.II.4.23.3 Accessed January 25, 2021.
Last Updated: February 3, 2017
Last Reviewed: June 10, 2019
Chapter Information

Definition, Etiology, PathogenesisTop

Hemorrhoids are vascular cushions in the anal canal, formed by the submucosa containing blood vessels, smooth muscle, and connective tissue. Three main vascular cushions are located in the left lateral, right anterior, and right posterior positions. Hemorrhoids are a part of normal anatomy with the potential to become symptomatic.

Hemorrhoids are classified as internal or external hemorrhoids depending on their location relative to the dentate line (above or below the dentate line, respectively). Mixed hemorrhoids have both components.

Clinical FeaturesTop

A common symptom is rectal bleeding (bright red blood on toilet paper or in the toilet bowl). It is rare to have significant bleeding that causes anemia. Prolapse is another common symptom.

Classification of internal hemorrhoids based on degree of prolapse is as follows:

1) Grade I: Enlargement of hemorrhoids without prolapse.

2) Grade II: Prolapse of hemorrhoids with spontaneous reduction.

3) Grade III: Prolapse of hemorrhoids requiring manual reduction.

4) Grade IV: Irreducible prolapse of hemorrhoids.

Sometimes patients complain of perianal pruritus. Sudden-onset pain is usually associated with thrombosed external hemorrhoids; it is rare in symptomatic internal hemorrhoids.

It is important to elicit information on bowel habits and any recent changes as well as family history.

Physical examination includes inspection of the perianal region, digital rectal examination, and anoscopy. Careful examination should be done to exclude other pathology (eg, fissure, abscess, fistula in ano, dermatitis, condyloma, inflammatory bowel disease, malignancy).


Physical examination and anoscopy/sigmoidoscopy is usually sufficient for diagnosis.

Colonoscopy should be performed in patients with rectal bleeding that is not typical for hemorrhoids (eg, blood is mixed with feces, anemia) or if indicated for other clinical reasons (eg, family history of colorectal cancer).


Treatment includes:

1) Conservative management:

a) Dietary and lifestyle changes: Dietary modification to achieve a high-fiber diet with fiber supplementation and increased water intake is the first-line conservative management for symptomatic hemorrhoids.Evidence 1Strong recommendation (benefits clearly outweigh benefits; right action for all or almost all patients). Moderate Quality of Evidence (moderate confidence that we know true effects of the intervention). Quality of Evidence lowered due to the risk of bias of primary studies. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev. 2005 Oct 19;(4):CD004649. Review. PubMed PMID: 16235372. Lifestyle modifications such as minimizing the time spent on the toilet and straining should be adopted to decrease symptoms.

b) Treatment of local symptoms (pruritus, burning sensation, pain) using warm sitz baths may be helpful. Suppositories/ointments containing ingredients such as local anesthetics and hydrocortisone have little science to support their use; however, some patients report relief.

2) Office-based procedures: In patients with grade I, II, and III hemorrhoids in whom medical treatment is ineffective, obliteration of hemorrhoidal tissue is performed in an outpatient setting. Available techniques include sclerotherapy, bipolar diathermy, infrared coagulation, and rubber band ligation. Rubber band ligation is the most common and effective method of office-based procedures but it still requires multiple repeat treatments.

3) Surgery: Surgery is reserved for symptomatic hemorrhoids that have failed conservative and office-based procedures, grade IV hemorrhoids, or mixed hemorrhoids with a significant external component. Acutely incarcerated (nonreducible) or strangulated (vascular compromise) internal hemorrhoids require emergency excisional hemorrhoidectomy. Hemorrhoidectomy is the most effective treatment; however, it is associated with significant pain and potential serious complications.

Thrombosed external hemorrhoids may require incision and evacuation of thrombus in patients who present within 72 hours of the onset of symptoms. Patients presenting later should be followed up without intervention because the pain associated with thrombosis usually resolves spontaneously within 7 to 10 days. Most patients do not require any intervention.

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