Snapshot A 68-year-old female presents to the clinic with complaints of of an anal mass. The patient also describes some blood on the tissue when she wipes. The mass is not painful and upon physical examination, protudes and increases in size with Valsava. Introduction Clinical definition condition where the vascular structures in the anal canal become swollen or inflamed site where channels of arteriovenous connective tissues drains into the superior and inferior hemorrhoidal veins 3 types of hemorrhoids external hemorrhoids are distal to the dentate line internal hemorrhoids are proximal to the dentate line mixed hemorrhoids are located both proximal and distal to the dentate line classification of internal hemorrhoids is based on the degree of prolapse grade I visualized via anoscopy do not prolapse below the dentate line grade II prolapse out of the anal canal with defecation or straining but reduce spontaneously grade III prolapse out of the anal canal with defecation or straining and require manual reduction grade IV irreducible and may strangulate Epidemiology demographics prevalence peaks between ages of 45-65 years equal distribution between the sexes risk factors age diarrhea pregnancy pelvic tumors prolonged sitting straining chronic constipation Pathogenesis not well understood but may be due to a variety of factors hemorrhoidal veins are normal anatomic structures within the submucosal layer in the lower rectum they arise from the hemorrhoidal cushion of dilated arteriovenous channels and connective tissue internal hemorrhoids arise from the superior hemorrhoidal cushion and is viscerally innervated and are not sensitive to pain, touch, or temperature external hemorrhoids arise from the inferior hemorrhoidal plexus and is somatically innervated and are extremely painful hemorrhoid symptoms can result when these structures slide downwards, venous pressure is excessively increased, or hypertrophy/increased tone of the anal sphincters Presentation Symptoms asymptomatic hematochezia pain (associated with external hemorrhoids) perianal pruritus fecal soilage Physical exam presence of hemorrhoids (more likely seen with external hemorrhoids) bluish elevation of skin (seen in thrombosed external hemorrhoid) possible skin tag Studies Physical examination inspection of anal verge and perianal area for external hemorrhoids, prolapsed internal hemorrhoids, or other possible causes of anal symptoms (e.g., condylomata) digital rectal examination (DRE) for palpation for masses, tenderness, and characterization of anal sphincter tone Anoscopy indicated in patients where hemorrhoids were not detected on physical examination and DRE allows for visualization and evaluation of the anal canal and distal rectum prolapsed internal hemorrhoids appear as dark pink, glistening, and sometimes tender masses at the anal margin Colonoscopy/flexible sigmoidoscopy indicated in patients > 40 years of age with risk factors for colorectal cancer (e.g., weight loss) Differential Anal fissures differentiating factors usually discernable via visualization of fissure Colorectal pathology (e.g., polyps) differentiating factors usually painless and will be visualized on colonoscopy Treatment Lifestyle modifications high fiber diet and hydration regular physical exercise avoid straining or lingering (e.g., reading) on the toilet limit fatty foods and alcohol Medical stool softeners (e.g., psyllium) topical analgesics and steroids sitz baths for acute flare-ups Surgical patients who have symptomatic internal hemorrhoids refractory to conservation treatments are referred for office-based procedures rubber band ligation sclerotherapy infrared coagulation excision indicated in cases of acutely thrombosed external hemorrhoids hemorroidectomy is indicated for patients who fail medical medication and/or cannot tolerate an office-based procedure often not indicated for external hemorrhoids Complications Exsanguination (may not have signs of external bleeding) Pelvic infection Incontinence Thrombosis Strangulation Ulceration Infection Anal fissures