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Contributors: Amirah Khan MD, Paritosh Prasad MD
Other Resources UpToDate PubMed


Hemorrhoids are characterized by dilated veins between the anal mucosa and internal anal sphincter. Hemorrhoids are a naturally occurring part of anal anatomy, and their presence does not necessarily correlate to symptoms. Internal hemorrhoids occur above the dentate line, and external hemorrhoids occur below the dentate line. Mixed hemorrhoids straddle the dentate line. Internal hemorrhoids can be graded based on degree of prolapse from anal canal:
  • Grade 1 protrudes into the anal canal but does not prolapse outside the anus.
  • Grade 2 protrudes out of anal canal with defecation / straining but spontaneously reduces.
  • Grade 3 prolapses out of the anal canal with defecation / straining but can be manually reduced.
  • Grade 4 prolapses into anal canal and is unable to be reduced.
Hemorrhoids are common in both males and females. Although hemorrhoids may occur at any age, they more commonly present in middle-aged adults. Risk factors for development of symptomatic hemorrhoids include advancing age, chronic constipation, diarrhea, pregnancy, prolonged sitting, and straining. Symptoms are due to prolapse of enlarged internal hemorrhoids into the anal canal, which increases trauma to the area. External hemorrhoids become symptomatic when inflamed or thrombosed.

Clinical manifestations of symptomatic hemorrhoids depend on whether internal or external hemorrhoids are present. Internal hemorrhoids are not sensitive to pain or temperature so they often present with painless rectal bleeding, prolapse, passage of mucus in stool, pruritus, or leakage of rectal contents. External hemorrhoids are covered by squamous epithelium, which contains pain receptors; therefore, symptoms include rectal pain, swelling, and pruritus.

Symptoms can last days to weeks and often require treatment with a high-fiber diet or fiber supplementation, sitz baths, and topical creams. If symptoms persist, these patients may require band ligation or surgery. Symptomatic hemorrhoids can recur in the future.


K64.9 – Unspecified hemorrhoids

70153002 – Hemorrhoids

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Diagnostic Pearls

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Differential Diagnosis & Pitfalls

  • Anal fissure
  • Anal fistula
  • Anal abscess
  • Anal spasm
  • Anorectal malignancy (see Anal cancer)
  • Colorectal cancer (see Rectal carcinoma)
  • Inflammatory bowel disease (see Crohn disease, Ulcerative colitis)
  • Solitary rectal ulcer
  • Genital wart

Best Tests

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Management Pearls

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Drug Reaction Data

Below is a list of drugs with literature evidence indicating an adverse association with this diagnosis. The list is continually updated through ongoing research and new medication approvals. Click on Citations to sort by number of citations or click on Medication to sort the medications alphabetically.

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Last Reviewed:01/03/2019
Last Updated:01/14/2019
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A medical illustration showing key findings of Hemorrhoids (Internal Hemorrhoids) : Anal pruritus, Dyschezia, Tenesmus, Painless hematochezia, Rectal mucous discharge
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