The clinical manifestations of internal and external hemorrhoids are different, and mixed hemorrhoids have symptoms and signs of internal and external hemorrhoids.
(1) Internal hemorrhoids:
1. Blood in the stool: In the early stage, blood is attached to the surface of the stool or on the toilet paper. Attacks are frequent but small. As the symptoms worsen. Internal hemorrhoids prolapse during defecation, which can be manifested as dripping or ejection, reducing the number of attacks, but the blood volume increases, which can reach tens of milliliters at a time. Repeated heavy bleeding can cause hemorrhagic anemia. The blood in the stool of hemorrhoids is painless, the blood is bright red, and can be bloody, dripping and ejection.
2. Prolapse: As the hemorrhoids increase in volume, they are impacted and squeezed by the feces during defecation, which separates the hemorrhoids from the muscle layer and prolapses outside the anus. In the initial stage, it only prolapses during defecation and can reset itself after defecation. When the symptoms worsen, they cannot repay by themselves after prolapse, and they need to return with their hands or rest in bed before resetting. In addition to prolapse during defecation in the later period, it can be prolapsed when exerting force, walking, coughing, sneezing, squatting or losing concentration. Hemorrhoids prolapse, the mucosa is prone to damage, infection, inflammation, edema, and pain. If it is not reset in time, it may be incarcerated, making it difficult to reset.
3. Pain: Simple internal hemorrhoids have no pain. If hemorrhoids are incarcerated or form infection, ulcers, or thrombosis, it can cause severe pain. When internal hemorrhoids are incarcerated, the patient has unbearable pain in the anus, restless sitting and lying, obstruction of defecation and qi, and sometimes reflexes cause urinary retention.
4. Anal swelling: Hemorrhoids can have different degrees of anal swelling in each period, and the late stage is more serious. In the middle and late stages, there may be a sense of incompleteness. The cause of the anal swelling may be the irritation of the rectal mucosa by the enlarged hemorrhoids, or the inflammation of the mucosa.
5. Mucus leakage, moist anus, itching: internal hemorrhoids prolapse, mucous membrane inflammation and erosion, increased exudate, late internal hemorrhoids due to anal sphincter relaxation, often secretions, intestinal leakage, pollution of underwear, the patient feels wet anus. Due to the stimulation of intestinal juice, the skin of the anus grows thick and becomes lichenoid, and itching is unbearable, especially at night.
6. Physical signs:
(1) Inspection: The appearance of the anus was normal in the early stage, and the anus was wet in the late stage, some of the anal canal moved downward, the hemorrhoids prolapsed from the anus, and some of the skin was hypertrophy, chapped, and erosive exudate.
(2) Proctoscopy: The mucosa in the hemorrhoid area on the dental line is uplifted and varies in size. Some mucosa is rosy and cherry-like, and the mucosa is erosive and bleeding. Some are fibrotic and the surface is gray. Internal hemorrhoids mostly occur at the ends of the branches of the superior rectal artery, namely in the three departments of the right anterior, left posterior and left side, namely the lithotomy position 3, 7, and 11 o'clock. These positions are often referred to as the mother hemorrhoid area in clinical practice. , The internal hemorrhoids that occur are called female hemorrhoids, and the adjacent secondary hemorrhoids are called child hemorrhoids.
(3) Digital examination: The internal hemorrhoids are small in the initial stage, and it is not easy to touch the hemorrhoids during the digital anal examination. In the middle and late stages, due to the increased volume of the hemorrhoids, some surface mucosal inflammation stimulates the proliferation and fibrosis, and the raised soft mass can be palpable. In severe cases, obvious arterial pulsations may be palpable. During the digital anal examination, care should be taken to exclude other anal pains, such as rectal polyps and rectal cancer.
(2) External hemorrhoids:
1. Pain: Pain is more common in thrombotic external hemorrhoids, usually 24-72 hours after the onset, severe pain, restlessness, so that it can be aggravated during activities. Inflammatory external hemorrhoids may have burning pain, and severe pain may occur when infected. Epidermal external hemorrhoids and varicose external hemorrhoids are generally painless. However, anal bulging may occur during the attack.
2. Protruding lumps: Due to the hyperplasia of connective tissues, external hemorrhoids can form lumps on the anal margin, which are of different sizes; women are mostly on the front side, the back side, or have a circular protrusion. Thrombotic external hemorrhoids and inflammatory external hemorrhoids can see redness, swelling and thrombosis. If ulcerated and infected, there may be discharge of secretions. Varicose external hemorrhoids generally do not see lumps, and some skin is loose, and soft lumps can be seen when squatting or venous stasis.
3. Itching: Inflammatory external hemorrhoids, or inflammation of the epidermis caused by secretions, flushing and erosion of the anal skin, patients may have itching discomfort, and itching is more severe at night.
4. Physical signs:
(1) Inspection: External hemorrhoids are generally visible. Varicose veins and external hemorrhoids can see loose anal skin and subcutaneous varicose veins. Thrombotic external hemorrhoids can be seen with limited edema and purple lumps under the skin. Inflammatory external hemorrhoids, the skin is red and swollen, or there is erosion and exudation.
(2) Palpation: inflammatory external hemorrhoids and thrombotic external hemorrhoids can be palpable induration and tenderness. Connective tissue external hemorrhoids are generally soft and without lumps; varicose external hemorrhoids are not easy to touch when they are not congested, and only soft lumps can be touched when they are filled.
1. Anemia: Long-term repeated blood in the stool can cause varying degrees of anemia. The patient is pale, mentally exhausted, weak, and slow. In severe cases, hemoglobin can drop to about 2g/L.
2. Anus relaxation: repeated prolapse of internal hemorrhoids, or old and weak, can lead to anal sphincter relaxation, intestinal leakage, and partial anal incontinence.
3. Anal eczema and itching: internal hemorrhoids prolapse, exudate and intestinal fluid overflow, which can stimulate the skin of the anal margin, causing erosion, skin hypertrophy, chapped and other eczema-like changes. The patient feels moist and itchy anus.