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The spectrum of piles related symptoms is really broad. The symptoms of internal hemorrhoids include itching, bleeding, swelling, mucus discharge, burning sensation, prolapse, and soiling. Patients also describe a feeling of fullness, the presence of a foreign body inside the anorectum, difficulties with the process of defecation or general discomfort while sitting. It is well accepted that internal hemorrhoids do not cause pain, as they originate above the linea dentata (there are very few nerve endings there). This line is important landmark due to its visibility and presence of rectal nerves below the line. This also the reason why inflamed external hemorrhoids can be very painful (they are below the line). Nevertheless, many patients with internal hemorrhoids complain of rectal pain, instead of itching or discomfort. Piles can also prolapse internally, causing a sensation of fullness and constant urge to defecate, even after a bowel movement. Severe pain may be caused by thrombosed or strangulated prolapsing hemorrhoids. But symptomatic pain is most commonly attributed to an anal fissure, which is often misdiagnosed as hemorrhoids.
An important aspect of the clinical presentation is the presence of rectal bleeding. The blood within the cushions is mainly arterial and normally the patients would notice bright red blood after the bowel movement. The bleeding is usually a result of the passing stool and straining efforts during the defecation. The blood should not be mixed into the stool, nor should it be with a darker color, which is an indicative of colorectal cancer. At times excessive bleeding might lead anemia, which is a more dangerous condition. You should always consult with a medical professional if you notice changes or have persistent complaints. It’s a good idea to be referred to a specialist, such as a gastroenterologist or a proctologist (colorectal surgeon).
Prolapsing internal hemorrhoids could also cause soiling, mostly mucus, blood or pieces of stool. This can make hygiene problematic and cause different psychological and socioeconomic issues.
External hemorrhoids occur outside of the anal verge and are easy to recognize. The main symptom of external hemorrhoids is the presence of firm (bluish) lump near the anus. External piles can be painful and cause irritation and swelling. They are more prone to thrombosis. Bleeding can occur after the clot erupts. In this case, patients could experience excruciating anal pain. The thrombosed hemorrhoids are slowly absorbed in the course of several weeks. Inflamed external hemorrhoids can be surgically removed during the first 72 hours. After this, the surgery can cause excruciating pain and is not advised. Another downside of the surgery is that it can sometimes leave the patient with skin tags that may not reduce in size. These skin tags can cause irritation and hygiene issues.
Tests and procedures to diagnose hemorrhoids include an examination of the perianal, the anal canal and the rectum. Careful and detailed evaluation of the symptoms is required since some anorectal diseases might render the physical examination impossible (such as acute anal fissure). Since the area is very intimate some people could feel too embarrassed to share and discuss. However, changes related to the bowel habits, especially symptoms, such as bleeding, should be carefully examined. Dark blood mixed within the stool could suggest the presence of colorectal cancer. Chronic constipation or diarrhea could suggest other problems, such as Crohn’s disease or Inflammatory bowel disease (IBD). Itching without bleeding could be an indicative for pruritis. Excruciating pain after bowel movements is most probably an anal fissure. Thus, a careful ascertainment of the symptoms is critical before proceeding to physical examination.
The physical examination is done in a specific position (most often the prone jack-knife position). The goal is to perform a visual examination of the anal canal and the rectum. On the outside, the surgeon could identify external hemorrhoids, or even very large prolapsed internal hemorrhoids, but also other perianal diseases – fistulas, abscesses, dermatitis, anal fissures.
The physician could also perform a digital examination of the anal canal using a gloved finger. The patient might be asked to squeeze his sphincter muscle, to strain or even cough. This could help identify weakened sphincter tone or prolapsing internal hemorrhoids.
But to complete a thorough internal visual inspection of the rectum the surgeon has to insert a special device, called anoscope (the procedure is called anoscopy). You could be asked to undergo a flexible sigmoidoscopy to evaluate any symptoms for rectal bleeding. If risk factors like family history, advanced age or excessive bleeding are presented, you should undergo colonoscopy. Generally, patients older than 45 years are asked to undergo colon evaluation. You can read more about colonoscopy here.