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 that cause anal discomfort and pain with defecation such as rectal cancer, anal fissure, anal abscess, and anal fistula.

Differentiating Hemorrhoids from other Diseases

Hemorrhoids should be differentiated from other diseases that cause 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 movement. 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. Appears as a progressive mass protrusion from the anus. The protrusion first appears with straining and defecation, then progresses to the degree when it is no longer 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 of 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 to it. Constipation due to fear of bowel movements. Fever, headache, and chills may accompany the pain. If the 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.
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 unprotected anal sex with an infected partner. Having multiple sexual partners is a risk factor and should be investigated. Condyloma acuminata presents with painless warts that vary in size, shape, and color. Pruritis and discharge may accompany the warts.	Anal condyloma acuminata may be accompanied by cervical, vaginal, or even ororpharyngeal warts, so the patient should be examined thoroughly.