History and exam

Key diagnostic factors

common

rectal bleeding

Most common symptom of hemorrhoids alongside intermittent protrusion. Usually bright bleeding in association with defecation or straining at stool.

intermittent protrusion

Most common symptom of hemorrhoids alongside rectal bleeding.

perianal pain/discomfort

Can be a feature of uncomplicated internal or external hemorrhoids. Severe in thrombosed external hemorrhoids; may be associated with feeling of incomplete evacuation.

Other diagnostic factors

common

anal pruritus

May result from internal hemorrhoid prolapse-associated moisture or fecal incontinence, or result from the difficulty to maintain hygiene with extensive external hemorrhoids.

tender palpable perianal lesion

Can form adjacent to the anal canal on the anal margin when there is acute thrombosis.

anal mass

A palpable anal mass may be present with prolapsing hemorrhoids.

Risk factors

strong

age between 45-65 years

Incidence of hemorrhoids peaks between the ages of 45-65 years, and declines after age 65 years.[5]

constipation

The presence of chronic constipation associated with straining at stool is associated with the repetitive elongation of the hemorrhoidal cushions and disruption of the supporting elements. This leads to the enlargement and engorgement of the hemorrhoidal tissue.[9]

pregnancy or space-occupying pelvic lesion

Pregnancy is often associated with the progressive development of hemorrhoidal symptoms.[10] Pathologic pelvic lesions, such as large ovarian cysts, can also encourage the development of hemorrhoidal symptoms. In both situations, there is increase in intra-abdominal/pelvic pressure with concomitant decrease in venous return causing increased anal vascular engorgement.

weak

hepatic insufficiency

There is little evidence that hepatic insufficiency or portal hypertension contributes to the formation of hemorrhoids, but these conditions can result in rectal varices.[11]

ascites

An increase in intra-abdominal pressure can be a contributing risk factor.

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