What is the initial approach for a patient complaining of hemorrhoids?

From the Guidelines

The initial approach for a patient complaining of hemorrhoids should focus on a thorough medical history and physical examination, including a digital rectal examination, to rule out other causes of lower gastrointestinal bleeding, as suggested by 1. When evaluating a patient with suspected hemorrhoids, it is crucial to consider other potential causes of their symptoms, such as anal fissures, perianal abscesses, or rectal varices, as highlighted in 1. Key aspects of the initial approach include:

• Collecting a focused medical history to identify the nature of the symptoms, such as the presence of bleeding, pain, or a lump, as recommended by 1.
• Performing a complete physical examination, including a digital rectal examination, to assess for any palpable abnormalities or tenderness, as suggested by 1.
• Checking vital signs and evaluating the severity of any bleeding by determining hemoglobin and hematocrit levels, as well as assessing coagulation, as recommended by 1.
• Considering further evaluation, such as anoscopy and flexible sigmoidoscopy, or even complete colonic evaluation by colonoscopy, especially if the bleeding is atypical for hemorrhoids or if the patient has risk factors for colonic neoplasia, as advised by 1. A strong recommendation based on moderate-quality evidence from 1 supports non-operative management as the first-line therapy for complicated hemorrhoids, emphasizing dietary and lifestyle changes, such as increased fiber and water intake, along with adequate bathroom habits. Additional measures can include over-the-counter topical treatments and warm sitz baths to provide symptomatic relief and reduce inflammation, as part of a conservative management approach. If symptoms persist or worsen, referral for further medical evaluation and potential advanced treatments may be necessary.

From the Research

Initial Approach for Hemorrhoids

When a patient complains of hemorrhoids, the initial approach involves:

• Assessing the patient's history and physical examination to determine the extent of pain or discomfort, risk factors, and clinical signs indicating more concerning disease processes 2
• Evaluating the degree of discomfort, bleeding, comorbidities, and patient preference to determine the order of treatments 2
• Considering the classification of hemorrhoids, with internal hemorrhoids traditionally graded from I to IV based on the extent of prolapse 2

Treatment Options

Treatment options for hemorrhoids include:

• Medical management, such as stool softeners, topical over-the-counter preparations, and topical nitroglycerine 2
• Dietary modifications, including increased fiber and water intake 2, 3
• Behavioral therapies, such as sitz baths 2
• Office-based treatments, including rubber band ligation, which is the preferred next step if medical management is unsuccessful 2, 4, 5
• Surgical options, such as hemorrhoidectomy, which should be reserved for recurrent or higher-grade disease 2, 3, 5

Important Considerations

It is essential to note that:

• Hemorrhoids can be symptomatic, with rectal bleeding being a common symptom 3, 6
• The abnormal dilatation and distortion of the vascular channel, together with destructive changes in the supporting connective tissue within the anal cushion, is a key finding in hemorrhoids 3
• Special attention should be given to immunocompromised patients, as they may be at risk for coexisting infections, such as varicella zoster virus infection 6