Patients with thrombosed external hemorrhoids describe an acutely painful mass at the rectum. Pain truly caused by hemorrhoids usually arises only with acute thrombus formation. This pain peaks at 48-72 hours and begins to decline by the fourth day as the thrombus organizes. New-onset anal pain in the absence of a thrombosed hemorrhoid should prompt investigation for an alternate cause, such as an intersphincteric abscess or anal fissure.
Inspect and examine the entire perianal area. Warn the patient before any digital examination and probing. Because patient apprehension is great before any anal examination, go to great lengths to reassure the patient. Gentle spreading of the buttocks allows easy visualization of most of the anoderm; this includes the distal anal canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without internal probing. Note the location and size of skin tags, and look for the presence of thromboses. Normal corrugation of the anoderm and a normal anal wink with stimulation confirms intact sensation.
Digital examination of the anal canal can identify any indurated or ulcerated areas. Also assess for any masses, tenderness, mucoid discharge or blood, and rectal tone. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft vascular structures, they are usually not palpable unless thrombosed.
Current guidelines from most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids, such as in the presence of strong risk factors for colonic cancer, or in the setting of rectal bleeding with a negative anorectal examination.
For more on the presentation and physical examination of hemorrhoids, read here.
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