Hemorrhoids are vascular-rich connective tissue cushions located within the anal canal. Internal hemorrhoids lie proximal to the dentate line in the anal canal; external hemorrhoids are located distal to the dentate line.
Hemorrhoidal disease presents as painless rectal bleeding or sudden onset of perianal pain with a tender palpable perianal mass.
Diagnosis is confirmed with visualization of the protruding tissue or anoscopic visualization.
Treatment for all patients includes increasing dietary fiber. Rubber band ligation is a reasonable first-line treatment choice for grade 2 and 3 internal hemorrhoids. Other treatment options for grade 2 or 3 hemorrhoids include sclerotherapy, infrared coagulation, hemorrhoid arterial ligation, or stapled hemorrhoidopexy. Surgical hemorrhoidectomy may be considered for patients with large grade 3 hemorrhoids, but it is typically reserved for patients with grade 4 hemorrhoids.
Complications include recurrence or worsening of symptoms, excessive bleeding, nonreducible prolapse, and, rarely, pelvic sepsis.
Hemorrhoidal cushions are normal anatomic structures located within the anal canal, usually occupying the left lateral and right anterior and posterior positions. As they enlarge, they can protrude outside the anal canal causing symptoms.
History and exam
Key diagnostic factors
- rectal bleeding
- intermittent protrusion
- perianal pain/discomfort
Other diagnostic factors
- anal pruritus
- tender palpable perianal lesion
- anal mass
- age between 45-65 years
- pregnancy or space-occupying pelvic lesion
- hepatic insufficiency
1st investigations to order
- anoscopic exam
- colonoscopy/flexible sigmoidoscopy
- stool for occult heme
all patients at presentation
treatment failure of rubber band ligation, sclerotherapy, infrared coagulation, transanal hemorrhoidal dearterialization, or stapled hemorrhoidopexy
Mohamed A. Thaha, PhD, FRCS (Gen Surg), PG Cert Hlt Econ
Senior Lecturer and Consultant in Colorectal Surgery
National Bowel Research Centre (NBRC)
Barts and The London School of Medicine & Dentistry
Queen Mary University of London
Colorectal & Pelvic Floor Services
Royal London Hospital
Barts Health NHS Trust
MAT declares that he has no competing interests.
Robert J.C. Steele, MD, FRCS
Professor of Surgery
Ninewells Hospital & Medical School
University of Dundee
RJCS declares that he has no competing interests.
Dr Mohamed A. Thaha and Professor Robert J.C. Steele would like to gratefully acknowledge Dr Kurt G. Davis and Dr Jayan D. Jayasinghe, the previous contributors to this topic.
KGD and JDJ declare that they have no competing interests.
George Reese, MB BS MRCS
Honorary Clinical Research Fellow
Division of Surgery
Reproductive Biology and Anaesthetics
St Mary's Hospital
GR declares that he has no competing interests.
Alexander von Roon, MRCS
Clinical Research Fellow
Department of Biosurgery and Surgical Technology
St Mary's Hospital
AVR declares that he has no competing interests.
- Anal fissure
- Crohn disease
- Ulcerative colitis
- ACG clinical guidelines: management of benign anorectal disorders
- The European Society of Coloproctology: guideline for haemorrhoidal disease
HemorrhoidsMore Patient leaflets
- Log in or subscribe to access all of BMJ Best Practice
Use of this content is subject to our disclaimer