Document the patient’s bowel habits, including constipation, diarrhea, urgency, frequency, and changes in bowel habits. A prospectively maintained bowel diary may be helpful.

History can help differentiate hemorrhoids from other anal pathology. It can also elicit “red flag” symptoms such as bleeding or change in bowel habits that may be indicative of malignancy.

Dietary history is included particularly focusing on fiber and fluid intake with attention to foods that cause diarrhea or constipation.

Changes in bowel and diet habits due to an acute illness or travel should be noted.

Includes a general exam that focuses on liver disease, COPD, or coagulopathy.

The abdominal exam will focus on signs of constipation.

An anal exam may be embarrassing and same gender chaperone should be offered to be in the room to help relax the patient. Also reassure your patient and communicate what you will be doing.

The prone jackknife position allows for maximal anal exposure. If impractical (too obese, pregnant, or orthopedic issues), then left lateral or lithotomy position is chosen.

Describe anatomy and pathology in anatomical terms (left, right, anterior, posterior), and avoid using the position of the clock (patient’s position may change).

Inspect the anoderm and sacrococcygeal region. Identify external hemorrhoids, skin tags, prolapsing internal hemorrhoids, rectal prolapse, excoriated skin, fissures, fistulas, abscesses, anal cancer, thrombosed external hemorrhoids, rashes, or dermatitis.

Palpate the area to assess induration, tenderness, masses, or thrombus in external hemorrhoids.

Use the digital exam to assess sphincter tone (both rest and squeeze), and identify masses, abscesses, and localized pain.

The degree of prolapse is examined by asking the patient to strain. If there is any concern, an evaluation with the patient on a commode (which is a more physiologic situation) may be required.

Anoscopy is performed using one of the several types of anoscopes available (Fig. 11.1).

Rigid or flexible proctoscopy evaluates the rectum for inflammation.

Colonoscopy or barium enema is ordered if red flag symptoms are present. These are considered in the context of the patient’s age, personal and family history of colorectal pathology, duration of symptoms, and nature of bleeding. Due to concerns of inflaming hemorrhoids with a bowel preparation, treatment of the hemorrhoids for several weeks to months may be reasonable prior to a more in-depth colonic evaluation.

Modify stool through increased dietary fiber (25 g/day for women and 38 g/day for men) and increased water intake (64 oz daily).

Encourage regular sleep/wake cycle and exercise to maintain regular bowel habits.

Add bulk-forming agents such as psyllium to modify quality of stool (Table 11.2). Taken with oral fluid, the goal is to add moisture and soften stools. Optimally, patients should ingest supplements in the morning so fluid can be consumed throughout the day to hydrate the supplements. If needed (inadequate stool mixing), divide doses throughout the day. Long-term compliance may be difficult due to poor palatability, bloating, excessive flatus, or crampy abdominal pain. Start at a low dose and titrate up for the desired effect to minimize side effects.

Stool softeners (docusate), lubricants (mineral oil), and laxatives (hyperosmolar [polyethylene glycol], saline [magnesium citrate], or stimulant [senna or bisacodyl]) are used to treat constipation. Transition to fiber and stool softeners as quickly as feasible. Goal is a bulky but soft stool that is easy to pass.

Diarrhea may require additional evaluation including diet recommendations to increase fiber and reduce fat consumption, along with assessment of caffeine intake, alcohol intake, and irregular sleep/wake cycle which can all contribute to diarrhea. Profound or bloody diarrhea needs further evaluation with stool cultures, fecal fat analysis, and endoscopy. Loose stools can be treated with fiber supplementation that is titrated according to the patient’s symptoms.

The trial of increased fiber should be from 4 to 6 weeks followed by reevaluation of symptoms. The goal of medical management is symptom control. The appearance of the hemorrhoids may not change.

Many office-based treatments are available and choice depends on surgeon experience, patient preference, availability of equipment, and the medical status of patient.

All techniques are directed at internal hemorrhoids that lack somatic innervation allowing these treatments to be applied proximal to the dentate line.