How do you document hemorrhoids on a physical exam?

Documenting Hemorrhoids on Physical Exam

Document hemorrhoids by performing a focused medical history, visual inspection of the perianal area, digital rectal examination, and anoscopy when feasible, noting the type (internal vs. external), grade (for internal hemorrhoids), presence of thrombosis or strangulation, and associated findings. 1

Essential History Components

When evaluating suspected hemorrhoids, collect specific information about:

• Bleeding characteristics: Timing relative to defecation, color (bright red suggests hemorrhoidal source), amount, and whether blood is on toilet paper, coating stool, or mixed throughout 1, 2
• Pain severity and timing: Acute severe pain suggests thrombosis or strangulation, while painless bleeding is typical of uncomplicated internal hemorrhoids 1
• Prolapse pattern: Whether tissue protrudes during defecation, reduces spontaneously, requires manual reduction, or is irreducible 3, 4
• Bowel habits: Constipation, straining, and hard stools are key risk factors 2, 5
• Red flag symptoms: Personal or family history of colorectal cancer, inflammatory bowel disease, or other concerning features that warrant further investigation 1

Physical Examination Technique

Visual Inspection

• Examine the perianal area for external hemorrhoids, skin tags, thrombosed hemorrhoids (bluish, tense, tender masses), or prolapsed internal hemorrhoids 1
• Note any associated findings: Anal fissures, abscesses, condylomas, or signs of inflammatory bowel disease 1

Digital Rectal Examination

• Perform DRE to assess sphincter tone, palpate for masses, and rule out other causes of bleeding 1
• Recognize limitations: Internal hemorrhoids are typically not palpable on DRE; thrombosed or strangulated hemorrhoids may be too painful for adequate examination 1

Anoscopy

• Perform anoscopy as part of the physical examination whenever feasible and well tolerated to directly visualize internal hemorrhoids 1
• Important caveat: Patients with thrombosed or strangulated hemorrhoids often experience excruciating pain, making anoscopy impossible without proper sedation 1

Documentation Framework

For Internal Hemorrhoids

Document using Goligher's grading system 3, 4:

• Grade I: Hemorrhoids that bulge into the anal canal but do not prolapse
• Grade II: Prolapse beyond the anus during straining but reduce spontaneously
• Grade III: Prolapse that requires manual reduction
• Grade IV: Irreducible prolapse

For External Hemorrhoids

Document:

• Location (clock position when patient in lithotomy position)
• Size (approximate diameter in centimeters)
• Presence of thrombosis: Tense, bluish, tender nodule 3, 6
• Acuity: Duration of symptoms if thrombosed (critical for treatment decisions—excision within 72 hours reduces pain and recurrence) 3, 7

For Mixed Hemorrhoids

• Document both internal and external components separately using the above criteria 3, 6

Vital Signs and Laboratory Assessment

When bleeding is present:

• Check vital signs to assess hemodynamic stability 1
• Obtain hemoglobin and hematocrit to evaluate severity of bleeding 1
• Assess coagulation parameters if patient has bleeding disorder or takes anticoagulants 1
• Consider blood typing and cross-matching if severe bleeding is present 1

Common Pitfalls to Avoid

• Never blindly attribute rectal bleeding to hemorrhoids without adequate examination, as colorectal cancer, inflammatory bowel disease, and other serious conditions can present similarly 1
• Do not overlook concomitant anorectal pathology: Hemorrhoids may coexist with abscesses, fissures, inflammatory bowel disease (3.3-20.7% of IBD patients have symptomatic hemorrhoids), or malignancy 1
• Recognize when further evaluation is needed: Blood mixed throughout stool (rather than just on surface), persistent bleeding despite conservative management, or concerning personal/family history warrant colonoscopy 1, 2

When Additional Imaging or Endoscopy Is Indicated

• Perform imaging (CT, MRI, or endoanal ultrasound) only if suspicion exists for concomitant anorectal diseases such as abscess, inflammatory bowel disease, or neoplasm 1
• Proceed to colonoscopy when there is concern for inflammatory bowel disease or cancer based on patient history, family history, or physical examination findings 1