What are the symptoms of internal hemorrhoids?

Symptoms of Internal Hemorrhoids

Internal hemorrhoids most commonly present with painless, bright red rectal bleeding during defecation, often accompanied by tissue prolapse through the anal canal, mucus discharge causing perianal itching and irritation, and occasionally a sensation of incomplete evacuation. 1, 2

Primary Presenting Symptoms

Bleeding Characteristics

• Bright red blood is the hallmark symptom, typically dripping or squirting into the toilet bowl due to arterial oxygen tension from arteriovenous communications within the anal cushions 1
• Blood appears on toilet paper, on the surface of stool, or in the toilet bowl 3, 4
• Bleeding occurs specifically during or immediately after defecation 1, 5
• The bleeding is characteristically painless unless complications develop 3, 4

Tissue Prolapse

• Internal hemorrhoids are graded by degree of prolapse: Grade I (bleeding only, no prolapse), Grade II (prolapse with spontaneous reduction), Grade III (requiring manual reduction), and Grade IV (irreducible prolapse) 2, 3
• Prolapsing tissue creates a sensation of fullness or incomplete evacuation 1
• Patients may feel a lump or mass protruding from the anus during or after bowel movements 2

Mucus Discharge and Perianal Irritation

• Prolapse of rectal mucosa leads to continuous mucus deposition on perianal skin, causing chemical irritation 1, 6
• This mucus secretion results in itching (pruritus ani) and perianal discomfort 1, 6
• Visible perianal erythema and inflammation may develop from chronic mucus exposure 6

Important Distinguishing Features

What Internal Hemorrhoids Do NOT Typically Cause

• Anal pain is generally NOT associated with uncomplicated internal hemorrhoids 1, 2
• Pain suggests other pathology such as anal fissure (present in up to 20% of hemorrhoid patients), thrombosed external hemorrhoid, perianal abscess, or incarceration 1, 2
• Internal hemorrhoids are not palpable on digital rectal examination because they are soft, compressible vascular cushions that collapse under the examining finger 6
• Hemorrhoids alone do not cause positive fecal occult blood tests; occult bleeding suggests more proximal pathology requiring colonoscopy 1, 2

Critical Clinical Pitfalls

When to Suspect Alternative Diagnoses

• Never assume all anorectal symptoms are from hemorrhoids without proper examination 1, 6
• Darker blood or blood mixed in stool suggests a more proximal bleeding source requiring investigation 1
• Anemia from hemorrhoidal bleeding is rare (0.5 per 100,000 population) and should prompt evaluation for other causes 1, 2
• Any patient with rectal bleeding and risk factors for colorectal cancer (age >50 years) requires colonoscopy regardless of visible hemorrhoids 4

Essential Diagnostic Evaluation

• Anoscopy with adequate lighting is the gold standard for visualizing internal hemorrhoids, as they cannot be reliably diagnosed by digital examination alone 6
• External visual inspection identifies prolapsed internal hemorrhoids extending beyond the anal verge 6
• Complete colonic evaluation by colonoscopy is indicated when bleeding is atypical, no source is evident on anorectal examination, or significant risk factors for neoplasia exist 1, 6