Hemorrhoids: Diagnosis and Treatment Options


Am Fam Physician. 2018 Feb 1;97(3):172-179.

  Patient information: A handout on hemorrhoids is available.

Author disclosure: No relevant financial affiliations.

Many Americans between 45 and 65 years of age experience hemorrhoids. Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures; therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue; however, this procedure has several potential postoperative complications. Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly. Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms.

Hemorrhoids develop when the venous drainage of the anus is altered, causing the venous plexus and connecting tissue to dilate, creating an outgrowth of anal mucosa from the rectal wall. However, the exact pathophysiology is unknown. Hemorrhoids occur above or below the dentate line where the proximal columnar transitions to the distal squamous epithelium (Figure 11). The anus is approximately 4 cm long in adults, with the dentate line located roughly at the midpoint.2 Hemorrhoids developing above the dentate line are internal. They are painless because they are viscerally innervated. External hemorrhoids develop below the dentate line and can become painful when swollen. The extent of prolapse of internal hemorrhoids can be graded on a scale from I to IV, which guides effective treatment (Figure 2). This grading system is incomplete, however, because it focuses exclusively on the extent of prolapse and does not consider other clinical factors, such as size and number of hemorrhoids, amount of pain and bleeding, and patient comorbidities and preferences.3

 Enlarge     Print


Clinical recommendationEvidence ratingReferences

Increasing fiber intake is an effective first-line, non-surgical treatment for hemorrhoids.


7, 912

Most patients who undergo excision of thrombosed hemorrhoids within two to three days of symptom onset achieve symptom relief.


7, 10, 1922

Rubber band ligation is considered the preferred choice in the office-based treatment of grades I to III hemorrhoids because of effectiveness compared with other office-based procedures.


7, 10, 21, 23, 37

Excisional (conventional) hemorrhoidectomy is effective for the treatment of grade III or IV, recurrent, or highly symptomatic hemorrhoids.


7, 9, 10, 21, 23, 3235

The use of Ligasure during conventional hemorrhoidectomy leads to decreased pain in the immediate postoperative period.


32, 34

Compared with conventional hemorrhoidectomy, stapled hemorrhoidopexy results in more frequent recurrence of symptoms and prolapse.


10, 3537

Hemorrhoidal artery ligation is an emerging therapy with early outcomes similar to conventional hemorrhoidectomy for grade II or III hemorrhoids.


28, 37

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.


Clinical recommendationEvidence ratingReferences

Increasing fiber intake is an effective first-line, non-surgical treatment for hemorrhoids.


7, 912

Most patients who undergo excision of thrombosed hemorrhoids within two to three days of symptom onset achieve symptom relief.


7, 10, 1922

Rubber band ligation is considered the preferred choice in the office-based treatment of grades I to III hemorrhoids because of effectiveness compared with other office-based pr

The Authors

show all author info

TIMOTHY MOTT, MD, FAAFP, is Family Medicine Specialty Leader to the Surgeon General of the U.S. Navy at Naval Hospital Pensacola (Fla.). Dr. Mott is also an associate professor of family medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md....

KELLY LATIMER, MD, MPH, FAAFP, is a family physician at U.S. Naval Hospital Sigonella, Catania, Italy. Dr. Latimer is also an associate professor of family medicine at the Uniformed Services University of the Health Sciences.

CHAD EDWARDS, MD, FACS, is a general/acute care/trauma surgeon at Hamilton Medical Center in Dalton, Ga. At the time the article was submitted, Dr. Edwards was a general surgeon at Naval Hospital Pensacola and an assistant professor of surgery at the Uniformed Services University of the Health Sciences.

Address correspondence to Timothy Mott, MD, FAAFP, Naval Hospital Pensacola Department of Family Medicine, 6000 West Hwy 98, Pensacola, FL 32512. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Pfenninger JL, Zainea GG. Common anorectal conditions: part I. Symptoms and complaints. Am Fam Physician. 2001;63(12):2391–2398....

2. Nivatvongs S, Stern HS, Fryd DS. The length of the anal canal. Dis Colon Rectum. 1981;24(8):600–601.

3. Yeo D, Tan KY. Hemorrhoidectomy—making sense of the surgical options. World J Gastroenterol. 2014;20(45):16976–16983.

4. U.S. Department of Health and Human Services; National Institutes of Health; National Institute of Diabetes and Digestive and Kidney Diseases. Hemorrhoids. NIH publication no. 11–3021. November 2010. https://www.niddk.nih.gov/health-information/health-topics/digestive-diseases/hemorrhoids/Documents/Hemorrhoids_508.pdf. Accessed October 25, 2016.

5. Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis. 2012;27(2):215–220.

6. Chong PS, Bartolo DC. Hemorrhoids and fissure in ano. Gastroenterol Clin North Am. 2008;37(3):627–644.

7. Jacobs D. Clinical practice. Hemorrhoids. N Engl J Med. 2014;371(10):944–951.

8. Kluiber RM, Wolff BG. Evaluation of anemia caused by hemorrhoidal bleeding. Dis Colon Rectum. 1994;37(10):1006–1007.

9. Siegel RL, Fedewa SA, Anderson WF, et al. Colorectal cancer incidence patterns in the United States, 1974–2013. J Natl Cancer Inst. 2017;109(8).

10. Rivadeneira DE, Steele SR, Ternent C, Chalasani S, Buie WD, Rafferty JL; Standards Practice Task Force of The American Society of Colon and Rectal Surgeons. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011;54(9):1059–1064.

11. Mounsey AL, Halladay J, Sadiq TS. Hemorrhoids. Am Fam Physician. 2011;84(2):204–210.

12. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev. 2005;(4):CD004649.

13. Shafik A. Role of warm-water bath in anorectal conditions. The “thermosphincteric reflex.” J Clin Gastroenterol. 1993;16(4):304–308.

14. Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, et al. Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg. 2006;93(8):909–920.

15. Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev. 2012;(8):CD004322.

16. Gorfine SR. Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum. 1995;38(5):453–456.

17. Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. 2001;44(3):405–409.

18. Patti R, Arcara M, Bonventre S, et al. Randomized clinical trial of botulinum toxin injection for pain relief in patients with thrombosed external haemorrhoids. Br J Surg. 2008;95(11):1339–1343.

19. Greenspon J, Williams SB, Young HA, Orkin BA. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Dis Colon Rectum. 2004;47(9):1493–1498.

20. Jongen J, Bach S, Stübinger SH, Bock JU. Excision of thrombosed external hemorrhoid under local anesthesia: a retrospective evaluation of 340 patients. Dis Colon Rectum. 2003;46(9):1226–1231.

21. Wald A, Bharucha AE, Cosman BC, Whitehead WE. ACG clinical guideline: management of benign anorectal disorders. Am J Gastroenterol. 2014;109(8):1141–1157.

22. Zuber TJ. Hemorrhoidectomy for thrombosed external hemorrhoids. Am Fam Physician. 2002;65(8):1629–1632.

23. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum. 1995;38(7):687–694.

24. Picchio M, Greco E, Di Filippo A, Marino G, Stipa F, Spaziani E. Clinical outcome following hemorrhoid surgery: a narrative review. Indian J Surg. 2015;77(suppl 3):1301–1307.

25. Sutherland LM, Burchard AK, Matsuda K, et al. A systematic review of stapled hemorrhoidectomy. Arch Surg. 2002;137(12):1395–1406.

26. Jutabha R, Jensen DM, Chavalitdhamrong D. Randomized prospective study of endoscopic rubber band ligation compared with bipolar coagulation for chronically bleeding internal hemorrhoids. Am J Gastroenterol. 2009;104(8):2057–2064.

27. Burch J, Epstein D, Sari AB, et al. Stapled haemorrhoidopexy for the treatment of haemorrhoids: a systematic review. Colorectal Dis. 2009;11(3):233–243.

28. von Roon AC, Reese GE, Tekkis PP. Haemorrhoids: haemorrhoidal artery ligation. BMJ Clin Evid. 2009;2009:0415.

29. Wolff BG, Culp CE. The Whitehead hemorrhoidectomy. An unjustly maligned procedure. Dis Colon Rectum. 1988;31(8):587–590.

30. Milligan ET, Morgan CN, Jones LE, Officer R. Surgical anatomy of the anal canal, and the operative treatment of haemorrhoids. Lancet. 1937;230(5959):1119–1123.

31. Ferguson JA, Heaton JR. Closed hemorrhoidectomy. Dis Colon Rectum. 1959;2(2):176–179.

32. Jayne DG, Botterill I, Ambrose NS, Brennan TG, Guillou PJ, O'Riordain DS. Randomized clinical trial of Ligasure versus conventional diathermy for day-case haemorrhoidectomy. Br J Surg. 2002;89(4):428–432.

33. Tan JJ, Seow-Choen F. Prospective, randomized trial comparing diathermy and Harmonic Scalpel hemorrhoidectomy. Dis Colon Rectum. 2001;44(5):677–679.

34. Nienhuijs S, de Hingh I. Conventional versus LigaSure hemorrhoidectomy for patients with symptomatic hemorrhoids. Cochrane Database Syst Rev. 2009;(1):CD006761.

35. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev. 2006;(4):CD005393.

36. Tjandra JJ, Chan MK. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum. 2007;50(6):878–892.

37. Trompetto M, Clerico G, Cocorullo GF, et al. Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement [published correction appears in Tech Coloproctol. 2016;20(3):201]. Tech Coloproctol. 2015;19(10):567–575.

38. Emile SH, Youssef M, Elfeki H, Thabet W, El-Hamed TM, Farid M. Literature review of the role of lateral internal sphincterotomy (LIS) when combined with excisional hemorrhoidectomy. Int J Colorectal Dis. 2016;31(7):1261–1272.

39. Liu JW, Lin CC, Kiu KT, Wang CY, Tam KW. Effect of glyceryl trinitrate ointment on pain control after hemorrhoidectomy: a meta-analysis of randomized controlled trials. World J Surg. 2016;40(1):215–224.

40. Davies J, Duffy D, Boyt N, Aghahoseini A, Alexander D, Leveson S. Botulinum toxin (Botox) reduces pain after hemorrhoidectomy: results of a double-blind, randomized study. Dis Colon Rectum. 2003;46(8):1097–1102.

41. Singh B, Box B, Lindsey I, George B, Mortensen N, Cunningham C. Botulinum toxin reduces anal spasm but has no effect on pain after haemorrhoidectomy. Colorectal Dis. 2009;11(2):203–207.

42. Ala S, Saeedi M, Eshghi F, Mirzabeygi P. Topical metronidazole can reduce pain after surgery and pain on defecation in postoperative hemorrhoidectomy. Dis Colon Rectum. 2008;51(2):235–238.

43. Wanis KN, Emmerton-Coughlin HM, Coughlin S, Foley N, Vinden C. Systemic metronidazole may not reduce posthemorrhoidectomy pain: a meta-analysis of randomized controlled trials. Dis Colon Rectum. 2017;60(4):446–455.

44. Toyonaga T, Matsushima M, Sogawa N, et al. Postoperative urinary retention after surgery for benign anorectal disease: potential risk factors and strategy for prevention. Int J Colorectal Dis. 2006;21(7):676–682.

45. McCloud JM, Jameson JS, Scott AN. Life-threatening sepsis following treatment for haemorrhoids: a systematic review. Colorectal Dis. 2006;8(9):748–755.

46. Gao XH, Wang HT, Chen JG, Yang XD, Qian Q, Fu CG. Rectal perforation after procedure for prolapse and hemorrhoids: possible causes. Dis Colon Rectum. 2010;53(10):1439–1445.

47. Simillis C, Thoukididou SN, Slesser AA, Rasheed S, Tan E, Tekkis PP. Systematic review and network meta-analysis comparing clinical outcomes and effectiveness of surgical treatments for haemorrhoids. Br J Surg. 2015;102(13):1603–1618.



Copyright © 2018 by the American Academy of Family Physicians.
This content is owned by the AAFP. A person viewing it online may make one printout of the material and may use that printout only for his or her personal, non-commercial reference. This material may not otherwise be downloaded, copied, printed, stored, transmitted or reproduced in any medium, whether now known or later invented, except as authorized in writing by the AAFP. Contact afpserv@aafp.org for copyright questions and/or permission requests.

Want to use this article elsewhere? Get Permissions

CME Quiz

More in AFP

Editor's Collections

Related Content

More in Pubmed


Dec 15, 2018

Access the latest issue of American Family Physician

Read the Issue

Email Alerts

Don't miss a single issue. Sign up for the free AFP email table of contents.

Sign Up Now

Navigate this Article