Diagnosing hemmorhoids

Since there is more than one type of hemorrhoids, it is essential to have a sufficient knowledge of the anatomy of the part, and to make a physical examination with such a degree of care that one will be able to differentiate between external and internal hemorrhoids.

The history of bleeding, or something protruding during defecation, is not sufficient to make a diagnosis of hemorrhoids.

Your physician will perform a thorough local inspection of the parts. A digital examination with a gloved finger may be done.
In order to get a good view of internal hemorrhoids an examination with an anoscope is often needed. An anoscope is a lighted, hollow tube. A proctoscopic examination is performed to evaluate the entire rectum.

To eliminate other possible causes an examination of the rectum and lower colon (sigmoid) with sigmoidoscopy, as well as an eximination of the entire colon, colonoscopy. Colonoscopy and sigmoidoscopy are diagnostic procedures which involve the use of flexible, lighted tubes inserted through the rectum.

Hemorrhoids are rare in children under six, and adults over sixty. In children one is likely to find rectal polypi, and prolapsus of the rectum; and in the aged malignant growths.

Questions your doctor may ask you:

- What is your occupation ?
- Do other members in your family have these problems (heredity) ?
- Have you had former treatment ?
- What are your present complaints ?
- How long has this trouble existed ?
- Do you have diarrhea or constipation ?
- Is there any pain ?
- If so, is it constant or intermittent ?
- Does it come on immediately, or some time after stool ?
- Does anything protrude from the rectum on going to stool ?
- If so, does it return spontaneously into the bowel ?
- Or do you have replace it ?
- Is there any discharge from the rectum, either blood, mucus or pus?
- Do you experience any trouble in controlling your wind or bowel movement ?

Questioning in this manner will lay a sound foundation for the basis of making a diagnosis, but a definite diagnosis can be made only by direct inpection of the anal orifice, anal canal, and the lower part of the rectum.

Simple external hemorrhoids will be observed as varicosed perianal veins encircling the anus. Their appearance is that of varicose veins in other parts othe body, and are usually made more prominent when the patient is asked to strain as he (or she) would at stool. They have a bluish color, are tortuous in their course, and lie directly under the skin, rarely extending more than one inch from the rectum. They are not adherent to the skin, and rapidly disappear on pressure. They seldom give any symptoms unless they become irritated or infected.

A thrombosed external hemorrhoid develops suddenly and there is a history of acute pain followed by a small circular swelling at, or near, the anal margin, covered with skin of dark blue or livid color and when of any size, it is smooth and shiny. It is usually single in number, but does also occur in multiple.

Connective tissue (sentinel piles, skin tabs): in this type there is usually a histroy of previous "attacks of piles" accompantied by very marked pain and itching, or a history of previous operation for dilatation of the sphincter ani muscle or removal of hemorrhoids.

On examination there are seen pendulous flaps of skin attached around the edges of the anus. The characteristic shape of many of the tumors has caused them to be termed "dog ear piles". These tumors cannot be replaced into the anal canal and do not disappear on pressure.

Frankly, this type is nothing more than hypertrophied skin tab with marked infiltration of connective tissue. Whem complication by infection occurs, there is intense pain, the mass becomes hard and tense. There is an increase in local temperature, and they are very tender to touch.

Internal hemorrhoids of the second degree when protruding, appear as bright red pear-shaped masses, protruding through the anus, and when returned back into the anal canal, practically disappear. Unless complicated by thrombosis or infection, they cannot be felt on digital examination, but they readily protrude into the lumen of the proctoscope on proctoscopic examination.

Internal hemorrhoids of the third degree are found protruding through the anus, covered with mucous membrane which has become thinked and leathery because of their exposure and irritation. The normal epithelial covering may be replaced by stratified squamous epithelium. There is usually a discharge of mucus, and in some cases it is responsible for considerable irritation of the surrounding structures.

The skin surrounding the anus in a great number of cases, is found loose and lax, and the normal folds and rugae are redundant in piles of the second and third degrees not complicated with fissure or infection. The sphincter ani muscles are usually relaxed.

In cases complicated with fissure or acute infection, the spincter ani muscle is found spasmodically contracted and there is intense pain on digital or proctoscopic examination.

Some cases of interal piles of the second and third degrees, periodically become the seat of an acute phlebitis; the skin around the anal margin is swollen and edematous and the patient complains of pain and tenesmus. This condition is commonly referred to as an "attack of piles". In cases where it cannot be reduced, it is called an irreducible hemorrhoid. It has a tendency to last for a few says and it gradually subsides.

In some cases the protruding parts are grasped so tightly by the sphincter ani muscle, that the circulation is obstructed; the protruding mass becomes greatly edematous and there is an extravasation of seum into the surrounding tissues and is known as a strangulated hemorrhoid. In very marked cases where the obstruction is complete, gangrene of the parts occurs.