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Prolapsing internal/external hemorrhoid
1. Almost all patients with symptoms of one kind or another in the anorectal region will complain of "hemorrhoids". It is important to try to define exactly what the symptoms are, to examine the anorectal area and document the findings prior to referral.
2. One should also inquire and document the nature and frequency of bowel movements. Patients who are constipated, have hard stools, strain at stools, or have infrequent bowel movements (e.g., every 3 days), should first have treatment directed at improving their bowel habit.
This can be done by giving them specific instructions on a high fiber diet. (see below).
3. Pain and bleeding with bowel movements is rarely the result of hemorrhoidal disease, and much more likely caused by anal fissure. Attempts to correct bowel habit should be tried prior to referral.
4. Patients with painless rectal bleeding and/or prolapse of tissue during defecation, not associated with hard bowel movements, straining, etc., should be referred for evaluation.
Strangulation of a prolapsed internal hemorrhoid is a rare but exceptionally painful complication of chronic hemorrhoidal prolapse, and requires immediate attention.