What are the signs and symptoms of hemorrhoids?

Signs and Symptoms of Hemorrhoids

The most common symptom of hemorrhoids is painless bright red rectal bleeding during defecation, often accompanied by tissue prolapse in more advanced cases. 1, 2

Classification and Presentation

Hemorrhoids are classified into two main types with distinct symptoms:

Internal Hemorrhoids

• Located above the dentate line and covered by rectal mucosa
• Typically painless due to visceral innervation
• Require anoscopy for proper visualization
• Classified by degrees according to the American Society of Colon and Rectal Surgeons 1:
  • First-degree: Bleeding without prolapse
  • Second-degree: Prolapse during defecation with spontaneous reduction
  • Third-degree: Prolapse requiring manual reduction
  • Fourth-degree: Irreducible prolapse

External Hemorrhoids

• Located below the dentate line, covered by anoderm and perianal skin
• Visible during external examination
• Can be painful due to somatic innervation
• When thrombosed, present as painful, bluish, tense subcutaneous lumps 1, 3

Common Symptoms

1. Rectal bleeding

   • Bright red blood during defecation
   • Blood on toilet paper or in toilet bowl
   • Typically painless with internal hemorrhoids 4, 5

2. Prolapse

   • Tissue protrusion through the anal canal
   • May reduce spontaneously or require manual reduction
   • Irreducible prolapse in severe cases 1, 2

3. Discomfort and irritation

   • Anal irritation
   • Itching (pruritus ani)
   • Mucus discharge 2

4. Pain

   • Usually absent with uncomplicated internal hemorrhoids
   • Present with thrombosed external hemorrhoids
   • Severe pain with strangulated hemorrhoids 3, 2

5. Swelling

   • Perianal fullness
   • Visible or palpable mass in external hemorrhoids 5

Important Clinical Considerations

• The presence of hemorrhoids should not delay evaluation for other causes of rectal bleeding, as hemorrhoids and colorectal cancer can coexist 1
• Up to 20% of hemorrhoid patients have concurrent anal fissures, which can cause similar symptoms 1
• Symptoms alone are not specific enough for definitive diagnosis, and anoscopy is essential for accurate assessment 1
• Dark blood, positive fecal occult blood test, anemia, age over 50 years, and family history of colorectal cancer warrant complete colonic evaluation 1

Warning Signs Requiring Further Investigation

• Dark or maroon-colored blood (not bright red)
• Unexplained weight loss
• Change in bowel habits
• Anemia
• Positive fecal occult blood test
• Age over 50 years 1, 5

Complications

• Thrombosis: Acute, painful swelling of external hemorrhoids
• Strangulation: Irreducible prolapse with compromised blood supply
• Anemia: In cases of significant chronic bleeding
• Incarceration: Prolapsed tissue that cannot be reduced 3, 2

The most recent evidence from JAMA (2025) indicates that hemorrhoidal disease affects approximately 10 million individuals in the US and may significantly impair quality of life due to the symptoms described above 2.