See your doctor if you think you might have hemorrhoids, especially if you notice bleeding from your anus or rectum or have bloody stools.
Your doctor will want to rule out more serious problems that can cause bleeding from the anus or rectum, such as cancer.
Hemorrhoid symptoms may also be similar to those of other anal and rectal problems, including anal fissures, abscesses, warts, and polyps.
Your doctor will perform a physical exam to look for hemorrhoids. This will involve a visual examination of the area.
It may also involve a rectal exam with a gloved, lubricated finger and a tool called an anoscope.
An anoscope is a type of endoscope, a hollow, lighted tube that is inserted a few inches into the anus to help the doctor see any problems inside the rectum.
Diagnosis of Hemorrhoids
Your doctor may also recommend additional tests to rule out other causes of bleeding, especially if you are over the age of 40. These tests may include:
Colonoscopy: Your doctor uses a thin, flexible tube called a colonoscope to look at the inner lining of your colon.
A colonoscopy can help discover ulcers, polyps, tumors, and other areas of inflammation or bleeding.
Sigmoidoscopy: This procedure is similar to a colonoscopy, but it uses a shorter tube called a sigmoidoscope to examine the lining of the rectum and the sigmoid colon (the lower part of the colon).
Barium enema X-ray: This is a special type of X-ray of the colon and rectum in which your doctor inserts a liquid solution containing barium sulfate into the rectum.
The solution helps highlight specific areas in the colon for your doctor to examine in the X-ray images.
Hemorrhoids Physical Examination
A visual inspection of the perianal area will allow for the description of any external abnormalities. The examination is classically performed in the prone or left lateral decubitus position, but generally the left lateral position is preferred because it is more comfortable for patients and typically less intimidating than the prone or prone jack-knife positions. Entities that may be encountered include skin rashes, external hemorrhoids or tags, fissures, fistulae, abscesses, neoplasms, condylomata, prolapse, hypertrophic papillae, or any combination thereof.
A digital rectal examination is also required. The digital rectal examination seems to be a bit of a “lost art” for many clinicians, but it is a tremendously important aspect of the evaluation of patients presenting with anorectal complaints. It should be stressed that the proper evaluation of the anal verge and its structures can provide important information that is useful in formulating a treatment plan for these patients. Care should be taken to evaluate the introitus, looking for signs of inflammation, skin lesions, and the anal sphincters, all of which can be evaluated in the anal canal. Too often, the digital rectal examination begins up in the rectum after the examining finger has passed through the internal sphincter, assuring that the examiner will not be able to appreciate evidence of scars, small fissures, origins of fistulae, and more. In addition to looking and palpating for any masses, lesions, areas of inflammatory change, fluctuance, tenderness, etc, characterizing the anal sphincters is an important feature of any digital examination. A careful examination will help depict the tone of the sphincters and whether the internal sphincter has separated from the external sphincter, amplifying the intersphincteric groove. This double sphincter sign can indicate the presence of coexistent sphincter spasm. In addition, a partially healed anal fissure can be deduced by the presence of thickening or scar in the posterior midline or roughening of the otherwise smooth anoderm. Palpation is important, because these areas may be difficult to see.
Some have suggested that descriptions of the physical position of any finding not be described by using the face of a clock but rather by using right/left and anterior/posterior in the description. Thus, for example, the left lateral hemorrhoid is at 3:00 when viewed in the classic supine position, 6:00 in the left lateral decubitus position, and 9:00 when in the prone position.
Anoscopy is a technique that seemingly is rarely taught in GI fellowship programs. It is the most accurate method for examining the anal canal and the distal-most rectum. With the availability of inexpensive disposable anoscopes, the procedure may be performed in the office on unprepped patients quickly, safely, and with minimum patient discomfort. There are a number of types of anoscopes available, but they can best be broken down into the categories of being slotted or non-slotted. Slotted anoscopes feature a cutout from the wall that allows the tissue in question to bulge into the slot, improving visibility, whereas in non-slotted anoscopes, no such cutout exists. Each has its advantages and disadvantages, but both offer an opportunity to visualize the anus and distal rectum in a manner that is not possible to do with a flexible endoscope. Non-slotted anoscopes do not require rotation to see pathology but tend to compress hemorrhoids; slotted anoscopes cannot be rotated because of patient discomfort and need to be completely withdrawn and rotated by using an obturator if the pathology is not identified on the initial pass.
Flexible Sigmoidoscopy and Colonoscopy
Flexible endoscopy is much more frequently performed to evaluate a patient with anorectal issues but appears to be not as accurate as anoscopy. In a prospective study, Kelley et al found that anoscopy identified 99% of anal lesions in subjects, whereas colonoscopy revealed only 78% when straight withdrawal of the scope was performed and only 54% during retroflexion. The limitation of flexible endoscopy pertaining to the anorectum emphasizes the importance of the anorectal physical examination as well as the advantages of incorporating the techniques of anoscopy in the GI setting.
There are some maneuvers that can be performed during flexible endoscopy to increase the accuracy and diagnostic yield in regard to the diagnosis of hemorrhoids and other anorectal issues. When performing a colonoscopy (or flexible sigmoidoscopy) and when in retroflexion, the act of insufflation causes the rectal vault to distend and stretch, and this can cause flattening of internal hemorrhoids. If the rectum is not partially deflated during this portion of the examination, the only hemorrhoids that can be seen are at or near the dentate line, ie, external hemorrhoids by definition. To more adequately evaluate this area, partial deflation will allow the hemorrhoidal tissue to become more obvious and easier to characterize; failure to do so will very likely underestimate the presence of hemorrhoidal disease. Excess air insufflation during flexible endoscopy can account for negative findings in patients presenting with a compatible hemorrhoid history, whereas anoscopic examination of these patients can reveal significant hemorrhoidal findings.
Another limitation of flexible endoscopy is the difficulty in describing the spatial orientation of the hemorrhoidal disease. A technique that can help with this dilemma is to irrigate the rectal cavity while examining for hemorrhoids. For example, when patients are in the left lateral decubitus position, fluid will tend to puddle in the dependent portion of the rectum on the patient’s left side. Therefore, the hemorrhoidal column that sits in or immediately adjacent to that puddle is the left lateral column. Once that point of reference has been established, the other hemorrhoids can be identified and described as well (personal communication, Mitch Guttenplan, MD, Atlanta, GA).
It should be stressed that even when using the tips mentioned above, there still is a role for anoscopy in the evaluation of these patients, particularly because it can be done in the office setting in an unprepped patient. The procedure is quick, relatively painless, and inexpensive, yet it can yield a significant amount of information.
Hemorrhoids Differential Diagnosis
|Disease/Condition||Differentiating Signs/Symptoms||Differentiating Tests|
|Anal fissure||Anal fissures are associated with painful bleeding on defecation and possibly a sentinel skin tag (sometimes reported by the patient as a “painful hemorrhoid”). Fissures are seen as linear tears in the anal mucosae, most commonly in the posterior midline of the anal canal.||Physical exam.|
|Crohn disease||Crohn disease affecting the large bowel can present with rectal bleeding and is associated with diarrhea rather than constipation. Family history of inflammatory bowel disease is often present.||Endoscopy findings highly variable, depending on disease activity. Characteristically shows “skip areas” with areas of disease with intervening areas of normal mucosa. Usually most severe in the cecum and right colon, with rectum often spared.|
|Ulcerative colitis||Ulcerative colitis commonly presents with rectal bleeding and is associated with diarrhea rather than constipation. Family history of inflammatory bowel disease is often present.||Endoscopy reveals diffuse inflammation and ulceration in cases of acute ulcerative colitis.|
|Colorectal cancer||History of altered bowel habits, anemia, colonic polyps, and positive family history suggest colorectal cancer.||Endoscopy may reveal mass, stricture, and obstruction. Blood tests commonly reveal anemia.|
|Anal fistula||Commonly bleeding with a history of a preceding abscess, with continued intermittent bloody/purulent drainage. Visualized as a punctuate opening on the anal margin adjacent to the anal canal.||Physical exam.|
|Rectal prolapse||Usually presents as protruding mass per rectum especially with straining. May be associated with mucus or blood-stained discharge, pain, and or fecal incontinence.||Physical exam. A defecogram may help distinguish between mucosal prolapse and a full thickness rectal prolapse. Examination under anesthesia (EUA) may be required to confirm and assess severity.|
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