Hemorrhoids are a common condition involving the enlargement and displacement of vascular cushions in the anal canal and lower rectum. About one in 20 Americans experience hemorrhoids, with the prevalence increasing to roughly half of adults over the age of 50. Symptoms range from minor discomfort and itching to bleeding and pain. Fortunately, most cases are manageable with conservative measures, and the process for seeking treatment follows a clear path based on the severity and persistence of symptoms.
Where to Start Your Medical Journey
Your primary care physician (PCP) is the appropriate first point of contact for evaluating hemorrhoid symptoms. The PCP confirms the diagnosis and distinguishes hemorrhoids from other causes of rectal symptoms, such as anal fissures, polyps, or colorectal cancer. Rectal bleeding always warrants a medical evaluation, as it should never be assumed to be only a hemorrhoid.
The initial consultation involves discussing your symptoms and medical history, followed by a physical examination. This exam may include a digital rectal exam or the use of an anoscope for visual inspection of internal hemorrhoids. If hemorrhoids are confirmed, the majority of cases are managed through conservative, first-line treatments.
These conservative strategies focus on reducing pressure and irritation. The PCP recommends lifestyle and dietary modifications, including increasing daily fiber intake (25 to 30 grams) and consuming adequate water to ensure soft stools. These changes reduce straining during bowel movements, which is a major contributing factor to hemorrhoid development.
Initial treatments also involve managing acute symptoms with over-the-counter options like topical creams and suppositories to reduce swelling and discomfort. Soaking the anal area in a warm water sitz bath several times a day is recommended for soothing inflammation. If symptoms do not resolve within a week, your PCP may recommend a referral for more advanced care.
When to See a Specialist
A referral to a specialist is the next step if symptoms persist after one or two weeks of conservative care or if the hemorrhoids are severe. The two main specialists involved are the gastroenterologist and the colorectal surgeon. The choice depends on the required level of intervention.
Gastroenterologist
A gastroenterologist focuses on the entire digestive tract and performs minimally invasive office procedures for internal hemorrhoids. These procedures are reserved for persistent internal hemorrhoids causing bleeding or prolapse. One common technique is rubber band ligation, where an elastic band is placed around the base of the hemorrhoid to cut off its blood supply, causing it to wither.
Sclerotherapy is another option, involving injecting a chemical solution directly into the hemorrhoid tissue to shrink it. A gastroenterologist may also be required if the diagnosis is uncertain or if a colonoscopy is necessary to investigate the source of rectal bleeding. These treatments are highly effective for internal hemorrhoids that fail to improve with initial management.
Colorectal Surgeon
A colorectal surgeon, also known as a proctologist, specializes in conditions of the colon, rectum, and anus, including complex hemorrhoidal disease. Referral is necessary for very large, severely prolapsed, or mixed internal and external hemorrhoids that have not responded to less invasive methods. The surgeon performs advanced treatments, including surgical removal of the hemorrhoids, known as hemorrhoidectomy.
Hemorrhoidectomy is considered for severe, grade IV internal hemorrhoids or large external hemorrhoids that cause significant pain or recurrence. Although less common than non-surgical approaches, surgery offers the lowest recurrence rate for advanced cases. The decision to see a surgeon is based on the size and severity of the hemorrhoid and the failure of all other management strategies.
Symptoms Requiring Immediate Medical Attention
Certain acute symptoms indicate a potential complication requiring immediate medical evaluation, often bypassing the PCP for urgent care or the emergency room. Profuse or uncontrollable rectal bleeding is a serious warning sign, as excessive blood loss can lead to anemia. Signs of significant blood loss, such as feeling dizzy, faint, or unusually weak, necessitate prompt care.
Intense, sudden pain around an external hemorrhoid can signal a thrombosed hemorrhoid, where a blood clot has formed. This condition causes severe discomfort and may require emergency incision and drainage to relieve pressure. A prolapsed internal hemorrhoid trapped outside the anus (strangulated hemorrhoid) also requires immediate attention to prevent tissue death.
A painful lump accompanied by a fever or the discharge of pus suggests a potential infection or abscess. This is a medical emergency requiring prompt drainage and antibiotic treatment.