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]

Overview

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

Differentiating Hemorrhoids from other Diseases

Hemorrhoids should be differentiated from other diseases causing anal discomfort and pain with defecation.

Disease	History	Physical exam findings	Sample image
Anal fissure	Anal fissure usually presents with tearing pain with every bowel movement. Pain usually lasts for minutes to hours after every bowel movements. 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.	Most fissures occur in the posterior midline of the anal canal. Skin tags in the perianal area may accompany chronic anal fissures.	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. Progressive mass protrusion from the anus. Protrusion at first with straining and defecation then progresses to the degree that it is no longer be replaced back. It presents with abdominal discomfort and incomplete defecation. Fecal incontinence and anal discharge. Pain is not usually present.	Mass protruding from the anus. Concentric mucosal rings are characteristic for rectal prolapse.	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. Pain is exacerbated with bowel movements but is not exclusive with it. Constipation due to fear of bowel movements. Fever, headache and chills might accompany the pain. If 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.	Perianal abscess
anal cancer	Rectal bleeding is the most common presentation. Mass sensation in the anus. Mucoid discharge may occur. Patient may give a history of anal condyloma (especially homosexual men). 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 anal unprotected sex with an infected partner. Multiple sexual partners is a risk factor and should be investigated. Condyloma accuminata presents with a painless warts that varies in size, shape and color. Pruritis and discharge might accompany the warts.	Anal condyloma accuminata may be accompanied by cervical, vaginal or even ororpharyngeal warts, so the patient should be examined thoroughly.	Condylomata acuminata