What should I do if I can't see any external hemorrhoids (piles) on examination of a patient?

Management of Hemorrhoids When External Hemorrhoids Are Not Visible on Examination

Perform anoscopy with adequate lighting to visualize internal hemorrhoids, as the absence of external hemorrhoids does not exclude hemorrhoidal disease—internal hemorrhoids are the most common cause of rectal bleeding and originate above the dentate line where they are not visible on external examination. 1, 2

Immediate Diagnostic Steps

Complete the Physical Examination

• Perform digital rectal examination (DRE) to assess for palpable masses, sphincter tone, and internal pathology that may not be visible externally 3
• Use anoscopy with proper lighting as the definitive method to visualize internal hemorrhoids, which originate above the dentate line and are the primary source of typical hemorrhoidal symptoms (painless bleeding, prolapse) 2, 3
• Evert the anal canal by applying traction with opposing thumbs to better visualize anal fissures and any subtle external pathology 2

Key Clinical Distinctions

• Internal hemorrhoids present with painless bright red rectal bleeding during defecation and possible prolapse, but are not visible on external examination 2, 4
• The absence of pain strongly suggests internal rather than external hemorrhoids, as pain typically indicates thrombosed external hemorrhoids, anal fissures, or abscesses 1, 2, 3
• Up to 20% of patients with hemorrhoids have concomitant anal fissures, which can be the actual source of symptoms 1, 2, 3

Grading Internal Hemorrhoids (If Visualized on Anoscopy)

Internal hemorrhoids are classified by prolapse severity: 2, 4

• Grade I: Bleed but do not prolapse
• Grade II: Prolapse with defecation but reduce spontaneously
• Grade III: Prolapse and require manual reduction
• Grade IV: Prolapsed and cannot be reduced

Critical Screening for Alternative Diagnoses

When to Pursue Further Investigation

• Perform colonoscopy if the patient has guaiac-positive stools, anemia, or constitutional symptoms (fever, weight loss, night sweats) to exclude inflammatory bowel disease or malignancy 3
• Evaluate for change in bowel habits (new constipation or diarrhea patterns) that suggests alternative pathology 3
• Consider sigmoidoscopy at minimum for all patients reporting rectal bleeding, as attributing symptoms to hemorrhoids without adequate examination is a common pitfall 3

Common Pitfalls to Avoid

• Never assume all anorectal symptoms are from hemorrhoids without performing anoscopy—this leads to missed diagnoses of fissures, polyps, or more serious pathology 1, 3
• Do not attribute anemia to hemorrhoids without colonoscopy to exclude proximal gastrointestinal pathology 3
• New-onset anal pain without visible external source may indicate a small intersphincteric abscess rather than hemorrhoids 1, 2
• Mistaking anal polyps for hemorrhoids is common—polyps are painless unless irritated and may require biopsy to exclude neoplasia 1

Initial Management Based on Findings

If Internal Hemorrhoids Are Confirmed (Grades I-III)

• Start conservative therapy: Increase dietary fiber and water intake, avoid straining during defecation 4, 5
• Consider phlebotonics (e.g., flavonoids) which reduce bleeding and pain in 70-85% of patients, though symptom recurrence reaches 80% within 3-6 months after cessation 4
• Office-based procedures (rubber band ligation, sclerotherapy, infrared coagulation) are indicated if conservative measures fail, with rubber band ligation achieving 89% symptom resolution 4, 5

If No Hemorrhoids Are Found

• Reassess for alternative diagnoses: anal fissures, polyps, inflammatory bowel disease, or proximal pathology 1, 3
• Proceed with colonoscopy if bleeding persists or red flag symptoms are present 3