Hemorrhoids differential diagnosis

External hemorrhoids

• External hemorrhoids are painful as the skin below the punctate line is sensitive to pain.^[1]
• Blood clots may form in external hemorrhoids.
• Thrombosed external hemorrhoids cause bleeding, painful swelling, or a hard lump around the anus.
• When the blood clot dissolves, extra skin is left behind. This skin can become irritated or itch.
• Excessive straining, rubbing, or cleaning around the anus may make symptoms, such as itching and irritation, worse.

Internal hemorrhoids

• The most common symptom of internal hemorrhoids is bright red blood on stool, on toilet paper, or in the toilet bowl after a bowel movement.
• Internal hemorrhoids that are not prolapsed are usually not painful.
• Prolapsed hemorrhoids often cause pain, discomfort, and anal itching

Skin examination

• Inspection of the anal verge may show scratch marks and skin tags.
• Inspection also may reveal external hemorrhoids or prolapsed internal hemorrhoids.

Digital rectal examination

• Digital rectal examination reveals the size and location of hemorrhoids.
• Thrombosed hemorrhoids are tender to palpation.
• Internal hemorrhoids are not palpable by digital rectal examination and the use of anoscope is mandatory.

• Anal fissure usually presents with tearing pain with every bowel movement.^[1]
• 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.^[2]
• Skin tags in the perianal area may accompany chronic anal fissures.

• Rectal prolapse most commonly occurs in multiparous females over 40 years old.^[3]
• 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.^[4]
• Concentric mucosal rings are characteristic of rectal prolapse.

• Perianal abscess presents with severe, continuous, dull, aching pain in the perianal area.^[5]
• 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.

• Rectal bleeding is the most common presentation.^[6]
• Mass sensation in the anus.
• Mucoid discharge may occur.
• Patient may give a history of anal condyloma (especially homosexual men).^[7]
• 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.

• 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.^[8]
• 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.^[9]