Hemorrhoids differential diagnosis

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Ahmed Younes M.B.B.CH [2]


Hemorrhoids should be differentiated from other diseases that cause anal discomfort and pain with defecation such as rectal cancer, anal fissure, anal abscess, and anal fistula.

Differentiating Hemorrhoids from other Diseases

Hemorrhoids should be differentiated from other diseases that cause anal discomfort and pain with defecation such as anal fissure, rectal prolapse and perianal abscess.

Disease History Physical exam findings Sample image

External hemorrhoids

  • External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.[1]
  • Blood clots may form in external hemorrhoids.
  • Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus.
  • When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch.
  • Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse.

Internal hemorrhoids

  • The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement.
  • Internal hemorrhoids that are not prolapsed are usually not painful.
  • Prolapsed hemorrhoids often cause pain, discomfort, and anal itching

Skin examination

  • Inspection of the anal verge may show scratch marks and skin tags.
  • Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids.

Digital rectal examination

External hemorrhoids - By Dr. Joachim Guntau - www.Endoskopiebilder.de, CC BY-SA 3.0, httpscommons.wikimedia.orgwindex.phpcurid=18660115
Anal fissure
  • Anal fissure usually presents with tearing pain with every bowel movement.[1]
  • Pain usually lasts for minutes to hours after every bowel movement.
  • Patient is typically afraid of going to the bathroom to avoid the pain, which leads to a viscious cycle. The fissure worsens the constipation and the constipation (hard stool) aggravates the fissure.
  • About two-thirds of the patients present with bright red blood streaks on toilet papers or on the surface of stools.
  • May be accompanied by pruritis and discharge.
Anal fissure - Own work, Public Domain, httpscommons.wikimedia.orgwindex.phpcurid=8885750
Rectal prolapse
  • Rectal prolapse most commonly occurs in multiparous females over 40 years old.[3]
  • Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer replaced back.
  • It presents with abdominal discomfort and incomplete defecation.
  • Fecal incontinence and anal discharge.
  • Pain is not usually present.
Rectal prolapse - By Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main - Dr. K.-H. Günther, Klinikum Main Spessart, Lohr am Main, CC BY 3.0, httpscommons.wikimedia.orgwindex.phpcurid=20649968
Perianal abscess
  • Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.[5]
  • Pain is exacerbated with bowel movements, but is not exclusive to it.
  • Constipation due to fear of bowel movements.
  • Fever, headache, and chills may accompany the pain.
  • If the abscess starts to drain, discharge of purulent or bloody fluid may be noticed.
  • Flatulent, erythematous, and tender area of skin overlying the abscess.
  • If abscess is deep, tenderness is elicited with digital rectal examination.
Anal cancer
  • Rectal bleeding is the most common presentation.[6]
  • Mass sensation in the anus.
  • Mucoid discharge may occur.
  • Patient may give a history of anal condyloma (especially homosexual men).[7]
  • Fecal incontinence.
  • On digital rectal examination, solid hemorrhagic mass that is firmly fixed to the surrounding structures is noted.
  • Femoral and inguinal lymph nodes may show lymphadenopathy secondary to spread of cancer.
Anal Cancer - By Internet Archive Book Images - httpswww.flickr.comphotosinternetarchivebookimages14598073128Source book page httpsarchive.orgstreamdiseasesofrectum00gantdiseasesofrectum00gant-pagen653mode1up, No restrictions, httpsc
Condylomata acuminata
  • Patient may give a history of unprotected anal sex with an infected partner.
  • Having multiple sexual partners is a risk factor and should be investigated.[8]
  • Condyloma acuminata presents with painless warts that vary in size, shape, and color.
  • Pruritis and discharge may accompany the warts.
  • Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.[9]


  1. Schlichtemeier S, Engel A (2016). "Anal fissure". Aust Prescr. 39 (1): 14–7. PMC 4816871Freely accessible. PMID 27041801. doi:10.18773/austprescr.2016.007. 
  2. Beaty JS, Shashidharan M (2016). "Anal Fissure". Clin Colon Rectal Surg. 29 (1): 30–7. PMC 4755763Freely accessible. PMID 26929749. doi:10.1055/s-0035-1570390. 
  3. Cannon JA (2017). "Evaluation, Diagnosis, and Medical Management of Rectal Prolapse". Clin Colon Rectal Surg. 30 (1): 16–21. PMID 28144208. doi:10.1055/s-0036-1593431. 
  4. Blaker K, Anandam JL (2017). "Functional Disorders: Rectoanal Intussusception". Clin Colon Rectal Surg. 30 (1): 5–11. PMID 28144206. doi:10.1055/s-0036-1593433. 
  5. Sahnan K, Adegbola SO, Tozer PJ, Watfah J, Phillips RK (2017). "Perianal abscess". BMJ. 356: j475. PMID 28223268. 
  6. Moureau-Zabotto L, Vendrely V, Abramowitz L, Borg C, Francois E, Goere D, Huguet F, Peiffert D, Siproudhis L, Ducreux M, Bouché O (2017). "Anal cancer: French Intergroup Clinical Practice Guidelines for diagnosis, treatment and follow-up". Dig Liver Dis. PMID 28610905. doi:10.1016/j.dld.2017.05.011. 
  7. Prigge ES, von Knebel Doeberitz M, Reuschenbach M (2017). "Clinical relevance and implications of HPV-induced neoplasia in different anatomical locations". Mutat. Res. 772: 51–66. PMID 28528690. doi:10.1016/j.mrrev.2016.06.005. 
  8. Wieland U, Kreuter A (2017). "[Genital warts in HIV-infected individuals]". Hautarzt (in German). 68 (3): 192–198. PMID 28160045. doi:10.1007/s00105-017-3938-z. 
  9. Köhn FM, Schultheiss D, Krämer-Schultheiss K (2016). "[Dermatological diseases of the external male genitalia : Part 2: Infectious and malignant dermatological]". Urologe A (in German). 55 (7): 981–96. PMID 27364818. doi:10.1007/s00120-016-0163-9.