What does a healthcare provider (doctor) do to check for hemorrhoids?

How Healthcare Providers Check for Hemorrhoids

A doctor evaluates hemorrhoids through a systematic approach starting with focused history-taking, followed by visual perianal inspection, digital rectal examination, and anoscopy when tolerated. 1, 2

Essential History Components

The provider should ask specific questions about bleeding characteristics:

• Timing relative to defecation - whether blood appears during, after, or between bowel movements 2
• Color and amount - bright red blood suggests hemorrhoids, while darker blood may indicate proximal sources 2
• Location of blood - on toilet paper, coating stool surface, or mixed throughout (the latter requires further investigation) 2, 3
• Pain characteristics - acute severe pain suggests thrombosis or strangulation, while painless bleeding is typical of uncomplicated internal hemorrhoids 2
• Bowel habits - constipation, straining, and hard stools are key risk factors 2
• Red flag symptoms - personal or family history of colorectal cancer, inflammatory bowel disease, weight loss, or anemia warrant colonoscopy 2, 3

Physical Examination Sequence

Visual Perianal Inspection

The provider examines the perianal area for:

• External hemorrhoids or skin tags 2
• Thrombosed hemorrhoids (bluish, tense, painful masses) 2
• Prolapsed internal hemorrhoids 2

Digital Rectal Examination

This must be performed to assess sphincter tone, palpate for masses, and rule out other causes of bleeding. 1, 2

Anoscopy

Anoscopy should be performed as part of the physical examination whenever feasible and well tolerated to directly visualize internal hemorrhoids. 1, 2 This allows grading of internal hemorrhoids (Grade I-IV) which guides treatment decisions. 4, 5

Vital Signs and Laboratory Assessment

When bleeding is present, the provider should:

• Check vital signs to assess hemodynamic stability 1, 2
• Obtain hemoglobin and hematocrit to evaluate bleeding severity 1, 2
• Assess coagulation parameters if the patient has bleeding disorders or takes anticoagulants 1, 2
• Consider blood typing and cross-matching if severe bleeding is present 1, 2

Critical Pitfalls to Avoid

Do not blindly attribute rectal bleeding to hemorrhoids without adequate examination, as colorectal cancer, inflammatory bowel disease, and other serious conditions can present similarly. 2

• Concomitant anorectal pathology such as abscesses, fissures, inflammatory bowel disease, or malignancy must not be overlooked 2
• A positive fecal occult blood test should never be attributed to hemorrhoids without colonoscopy 3
• Anemia from hemorrhoids is rare (0.5 per 100,000 population), so significant anemia warrants further investigation 3

When Additional Testing Is Required

Imaging Indications

Imaging (CT, MRI, or endoanal ultrasound) should be performed only if suspicion exists for:

• Anorectal abscess 1, 2
• Inflammatory bowel disease 1, 2
• Neoplasm 1, 2

Colonoscopy Indications

Colonoscopy should be performed when:

• Concern exists for inflammatory bowel disease or cancer based on patient history, family history, or physical examination 1, 2
• Blood is mixed throughout stool rather than coating it 2
• Positive fecal occult blood test is present 3
• Patient is over 50 years old or has other colorectal cancer risk factors 6
• Bleeding is atypical for hemorrhoids or no source is evident on anorectal examination 3