Outpatient / Gastroenterology


Last Updated: 03/29/2023

# Hemorrhoids

Internal Hemorrhoids: Grade I - do not prolapse, II - prolapse when strain and reduce at rest, III - reduce manually, IV - irreducible


-- Onset: ***

-- Pain: ***

-- Blood: *** (streaks on stool, end of defecation)

-- Red Flags: *** (CRC risk factors - age >50, weight loss, no screening

-- DDx: anal skin tags, condyloma acuminata, rectal prolapse, anal carcinoma, anal fissure, colon polyp


-- Lifestyle: *** High Fiber Diet, Increased fluid intake, exercise, avoid prolonged sitting, straining on the toilet

-- Constipation: *** Psyllium (Metamucil), Miralax, Colace

-- Meds: *** Sitz Baths 3 times daily; Preparation H (phenylephrine, witch hazel, or hydrocortisone) ointment or suppository up to 4 times daily; Anusol cream (zinc sulfate - astringent, pramoxine - anti-pruritic) twice daily for 7 days 

-- Referral: *** colorectal surgery - banding, sclerotherapy, cryotherapy, surgery

Template coming soon!

Patient Guidance and Information

New Hemorrhoids - Lifestyle Modifications and Treatment

You have hemorrhoids, which are dilated blood vessels in the anal region that can sometimes bleed, and sometimes be painful. They can be caused by constipation, excessive straining when stooling, and prolonged sitting. 

Lifestyle modifications include increasing fiber in your diet, drinking plenty of water, getting regular exercise, and avoiding prolonged periods of sitting. 

Examples of high-fiber foods you can incorporate into your diet include avocados, berries, lentils, beans, peas, oatmeal almonds, and chia seeds.

You can read this article for more information on foods with high fiber content: 

You should also avoid straining while on the toilet, and treat constipation with bulking agents like psyllium (Metamucil), Miralax, or stool softeners like Colace. 

You can try Sitz Baths, and over-the-counter topical medications like Preparation H or Anusol Cream to address the symptoms like pain and itching.

In certain circumstances, we can refer patients to a proctologist or colorectal surgeon to remove the hemorrhoids. 

If You Remember Nothing Else

Hemorrhoids are defined by whether they are above or below the dentate line and are painful when external, and are more likely to cause bleeding when internal. Treat a patient's constipation with psyllium and miralax to prevent straining and the development of hemorrhoids. Treatment includes Sitz baths up to 3 times daily or various Preparation H ointments or suppositories (which have medications like phenylephrine, witch hazel, and hydrocortisone) up to 4 times daily. In refractory cases, refer to colorectal surgery to consider then need for procedures. If there is persistent GI bleeding and you cannot attribute it to hemorrhoids, you should send the patient for a colonoscopy, especially if there are other red flag symptoms.

Clinical Pearls

  • When to Refer: persistent symptoms, large hemorrhoids, irreducible
  • Above the dentate line is painless but bleeds
  • There is no cutaneous innervation above the dentate line which comes from the endoderm, is made of columnar epithelium, supplied by the superior rectal artery (from the inferior mesenteric artery)
  • Avoid long-term use of topicals - can lead to sensitization
  • Rubber band ligation is the most common intervention - leads to ischemic necrosis → fibrosis

Trials and Literature

Other Resources