History and exam
Key diagnostic factors
common
presence of risk factors
Major risk factors include age between 45 and 65 years, history of constipation, pregnancy, and presence of a space-occupying pelvic lesion.
rectal bleeding
Most common symptom of haemorrhoids alongside intermittent protrusion. Usually bright bleeding in association with defecation or straining at stool.
intermittent protrusion
Most common symptom of haemorrhoids alongside rectal bleeding.
perianal pain/discomfort
Can be a feature of uncomplicated internal or external haemorrhoids. Severe in thrombosed external haemorrhoids; may be associated with feeling of incomplete evacuation.
Other diagnostic factors
common
anal pruritus
May result from internal haemorrhoid prolapse-associated moisture or faecal incontinence, or result from the difficulty to maintain hygiene with extensive external haemorrhoids.
tender palpable perianal lesion
Can form adjacent to the anal canal on the anal margin when there is acute thrombosis.
anal mass
A palpable anal mass may be present with prolapsing haemorrhoids.
Risk factors
strong
age between 45-65 years
Incidence of haemorrhoids peaks between the ages of 45-65 years, and declines after age 65 years.[5]
constipation
The presence of chronic constipation associated with straining at stool is associated with the repetitive elongation of the haemorrhoidal cushions and disruption of the supporting elements. This leads to the enlargement and engorgement of the haemorrhoidal tissue.[9]
pregnancy or space-occupying pelvic lesion
Pregnancy is often associated with the progressive development of haemorrhoidal symptoms.[10] Pathological pelvic lesions, such as large ovarian cysts, can also encourage the development of haemorrhoidal symptoms. In both situations, there is increase in intra-abdominal/pelvic pressure with concomitant decrease in venous return causing increased anal vascular engorgement.
weak
hepatic insufficiency
There is little evidence that hepatic insufficiency or portal hypertension contributes to the formation of haemorrhoids, but these conditions can result in rectal varices.[11]
ascites
An increase in intra-abdominal pressure can be a contributing risk factor.
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