What are the signs and symptoms of hemorrhoids?

Signs and Symptoms of Hemorrhoids

Bleeding is the most common presenting symptom of hemorrhoids, characterized by bright red blood that drips or squirts into the toilet bowl or appears on toilet paper, while darker blood mixed with stool suggests a more proximal source requiring further investigation. 1, 2

Primary Symptoms by Hemorrhoid Type

Internal Hemorrhoids

• Painless rectal bleeding during defecation is the hallmark symptom, typically bright red and occurring with bowel movements 1, 3, 4
• Prolapse of tissue from the anal canal, classified by grade: Grade I (bleeding without prolapse), Grade II (prolapse with spontaneous reduction), Grade III (prolapse requiring manual reduction), and Grade IV (irreducible prolapse) 2, 3
• Anal itching and mucus discharge occur when prolapsed internal hemorrhoidal tissue deposits mucus onto perianal skin, causing chemical irritation and visible erythema 5
• Discomfort or pressure sensation rather than severe pain, as internal hemorrhoids above the dentate line lack somatic sensory nerve afferents 1, 3

External Hemorrhoids

• Acute severe pain is the hallmark when external hemorrhoids become thrombosed, presenting with a painful, palpable perianal lump 1, 6, 3
• Visible or palpable perianal swelling that patients can feel externally 2, 7
• Bleeding may occur when local pressure causes erosion through overlying skin, though external hemorrhoids typically cause symptoms only when thrombosed 6, 3

Associated Symptoms

• Perianal irritation and itching from mucus secretion bathing the perianal skin, though this is nonspecific and may indicate inadequate hygiene, minor incontinence, or perianal dermatitis 1, 5
• Soiling or mucus discharge particularly with prolapsing hemorrhoids 2
• Perianal redness and inflammation from continuous mucus secretion onto perianal skin 5

Critical Diagnostic Pitfalls to Avoid

Never attribute all anorectal symptoms to hemorrhoids without proper examination, as other serious pathology including colorectal cancer, anal fissures, abscesses, and fistulas may be missed. 1, 2, 5

• Pain is NOT typical of uncomplicated internal hemorrhoids - severe anal pain suggests anal fissure (present in up to 20% of hemorrhoid patients), perianal abscess, or thrombosed external hemorrhoid 1, 2, 5
• Hemorrhoids alone do not cause positive fecal occult blood tests - guaiac-positive stools require complete colonic evaluation to exclude proximal pathology 1, 6
• Anemia from hemorrhoids is rare (0.5 patients per 100,000 population) - significant anemia warrants colonoscopy to rule out other causes 1, 6
• Off-midline symptoms or atypical presentations require evaluation for Crohn's disease, ulcerative colitis, HIV/AIDS, tuberculosis, syphilis, or malignancy 6

When Symptoms Require Urgent Evaluation

• Severe pain with fever and urinary retention suggests necrotizing pelvic sepsis, a rare but serious complication requiring emergency evaluation 6
• Hemodynamic instability (dizziness, tachycardia, hypotension) with bleeding indicates significant blood loss requiring immediate assessment 6
• Spreading perianal erythema with systemic signs suggests cellulitis or abscess rather than simple hemorrhoids 5
• Incarcerated, prolapsed, and gangrenous hemorrhoids (seen in 0.2% of pregnant women) may require urgent hemorrhoidectomy 1