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<div><div>Hemorrhoids: Clinical manifestations and diagnosis</div> <span><div><div> <div><div><select><option>Select Language</option> <option>Chinese</option><option>English</option></select></div> <div><span></span></div> </div></div></div></span><div><div><dl><dt><span> </span>Authors:</dt><dd><a>Ronald Bleday, MD</a></dd><dd><a>Elizabeth Breen, MD</a></dd><dt><span> </span>Section Editor:</dt><dd><a>J Thomas Lamont, MD</a></dd><dt><span> </span>Deputy Editor:</dt><dd><a>Zehra Hussain, MD, FACP</a></dd></dl><div><div><bdi><span>Literature review current through:</span>&nbsp;Jun 2025.</bdi></div><div><bdi><span>This topic last updated:</span>&nbsp;Jul 11, 2023.</bdi></div></div></div></div><div><p><span>INTRODUCTION</span></p><p>Hemorrhoids are normal vascular structures in the anal canal, arising from a channel of arteriovenous connective tissues that drains into the superior and inferior hemorrhoidal veins. The cardinal features of hemorrhoidal disease include bleeding, anal pruritus, prolapse, and pain due to thrombosis. This topic will review the anatomic classification, clinical manifestations, and diagnosis of hemorrhoids. The management of hemorrhoids are discussed in detail, separately. (See  <a>"Home and office treatment of symptomatic hemorrhoids"</a> and  <a>"Surgical treatment of hemorrhoidal disease"</a>.)</p><p><span>ANATOMY AND CLASSIFICATION</span></p><p>Hemorrhoids arise from a plexus or cushion of dilated arteriovenous channels and connective tissue. Hemorrhoidal veins are normal anatomic structures located in the submucosal layer in the lower rectum and may be external or internal based upon whether they are below or above the dentate line. Both types of hemorrhoids often coexist. Internal and external hemorrhoids communicate with one another and drain into the internal pudendal veins, and ultimately, the inferior vena cava. </p><p><span>Internal hemorrhoids</span><span>&nbsp;—&nbsp;</span>Internal hemorrhoids are proximal to or above the dentate line. Internal hemorrhoids arise from the superior hemorrhoidal cushion. Their three primary locations (left lateral, right anterior, and right posterior) correspond to the end branches of the middle and superior hemorrhoidal veins. The overlying columnar epithelium is viscerally innervated; therefore, these hemorrhoids are not sensitive to pain, touch, or temperature. Tissues above the dentate line receive visceral innervation, which is less sensitive to pain and irritation. Internal hemorrhoids are further subclassified into four grades based on the degree of prolapse from the anal canal. </p><p>Internal hemorrhoids are graded according to the degree to which they prolapse from the anal canal:</p><p></p><ul></ul>Grade I hemorrhoids are visualized on anoscopy and may bulge into the lumen but do not prolapse below the dentate line.<p></p><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a><a></a></div><div><div>To continue reading this article, you must sign in with your personal, hospital, or group practice subscription.</div>  <div><div><a> <span> Subscribe</span> </a></div> <div><a> <span> Sign in</span> </a></div></div></div><div>Disclaimer: This generalized information is a limited summary of diagnosis, treatment, and/or medication information. It is not meant to be comprehensive and should be used as a tool to help the user understand and/or assess potential diagnostic and treatment options. It does NOT include all information about conditions, treatments, medications, side effects, or risks that may apply to a specific patient. It is not intended to be medical advice or a substitute for the medical advice, diagnosis, or treatment of a health care provider based on the health care provider's examination and assessment of a patient's specific and unique circumstances. Patients must speak with a health care provider for complete information about their health, medical questions, and treatment options, including any risks or benefits regarding use of medications. This information does not endorse any treatments or medications as safe, effective, or approved for treating a specific patient. UpToDate, Inc. and its affiliates disclaim any warranty or liability relating to this information or the use thereof.
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