How are hemorrhoids diagnosed?

Most individuals who have hemorrhoids discover them in one of several ways. They either feel the lump of an external hemorrhoid when they wipe themselves after a bowel movement, note drops of blood in the toilet bowl or on the toilet paper, or feel a prolapsing hemorrhoid (protruding from the anus) after bowel movements. Severe anal pain may occur when an external hemorrhoid thromboses, or a prolapsing internal hemorrhoid becomes gangrenous. Symptoms of anal discomfort and itching may occur, but anal conditions other than hemorrhoids are more likely to cause these symptoms than hemorrhoids. (Hemorrhoids often get a “bum rap” for such symptoms since both hemorrhoids and other anal conditions are common and may occur together. For example, up to 20% of individuals with hemorrhoids also have anal fissures.)

By the history of symptoms, the physician can suspect that hemorrhoids are present. Although the physician should try his or her best to identify the hemorrhoids, it is perhaps more important to exclude other causes of hemorrhoid-like symptoms that require different treatment. These other causes – anal fissures, fistulae, perianal (around the anus) skin diseases, infections, and tumors – can be diagnosed on the basis of a careful examination of the anus and anal canal. If necessary, scrapings of the anus to diagnose infections and biopsies of the perianal skin to diagnose skin diseases can be done.

External hemorrhoids appear as a bump and/or dark area surrounding the anus. If the lump is tender, it suggests that the hemorrhoid is thrombosed. Any lump needs to be carefully followed, however, and should not be assumed to be a hemorrhoid since there are rare cancers of the perianal area that may masquerade as external hemorrhoids.

The diagnosis of an internal hemorrhoid is easy if the hemorrhoid protrudes from the anus. Although a rectal examination with a gloved finger may uncover an internal hemorrhoid high in the anal canal, the rectal examination is more helpful in excluding rare cancers that begin in the anal canal and adjacent rectum. A more thorough examination for internal hemorrhoids is done visually using an anoscope. An anoscope is a three-inch long, tapering, metal or clear plastic hollow tube approximately one inch in diameter at its viewing end. The anoscope is lubricated and inserted into the anus, through the anal canal, and into the rectum. As the anoscope is withdrawn, the area of the internal hemorrhoid(s) is well seen. Straining by the patient, as if they are having a bowel movement, may make the hemorrhoid(s) more prominent. Anoscopy also is a good way for diagnosing anal fissures.

At times, indirect anoscopy may be helpful. Indirect anoscopy uses a special mirror for visualizing a patient’s anus while the patient is seated and straining on a toilet. Indirect anoscopy allows the doctor to see the effects of gravity and straining on the anus. For example, the physician may be able to determine if what is prolapsing is a hemorrhoid, rectal lining, a rectal polyp, or the rectum itself (a condition called procidentia in which the rectum turns inside out and protrudes from the anus).

Whether or not hemorrhoids are found, if there has been bleeding, the colon above the rectum needs to be examined to exclude important causes of bleeding other than hemorrhoids. Other causes include, for example, colon cancer, polyps, and colitis (inflammation of the rectum and/or colon). This examination can be accomplished by either flexible sigmoidoscopy or colonoscopy, procedures that allow the doctor to examine approximately one-third or the entire colon, respectively.

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