Acute pain is usually constant and related to a visible mass. Pain occurring after a bowel movement is rarely due to a hemorrhoid complication, but is more likely due to a fissure or ulcerating anal mass. Chronic anal pain and pruritus are generally not symptoms of hemorrhoids, but rather other diseases including anal fissure, mucosal prolapse, anal mass, or anal fistula which may be associated with excessive moisture leading to pruritus. These symptoms are nonspecific, and the presence of hemorrhoids should not be presumed since more severe conditions such as inflammatory bowel disease and cancer can mimic hemorrhoidal symptoms. Patients with severe pain or incarcerated protrusions should be seen promptly.
Diagnosis is established with direct visualization by anoscopy or proctoscopy.
All patients with rectal bleeding should have their colon examined to rule out proximal sources of bleeding, even in the presence of enlarged hemorrhoids. Since most sources of bright red bleeding are within the reach of a flexible sigmoidoscope, patients should undergo flexible sigmoidoscopy as well as anoscopy to rule out other causes of bleeding. Intermittent protrusion or occasional bleeding does not require urgent consultation. However, patients with acute symptoms of bleeding, pain or incarcerated protrusions should be seen promptly. Outpatient surgical treatment is appropriate if conservative treatment fails and the patient desires relief of symptoms.