Investigations

Suspected haemorrhoids are investigated by:

• examining the abdomen, groins and genitals for masses, lymphadenopathy, etc.
  
  
• digital examination:
  • this is essential but should be done with care, especially if pain is a presenting symptom
  • helps to exclude carcinoma and provides a useful measure of anal tone
  • note that haemorrhoids are often not palpable on digital examination because they empty with pressure from the examining finger
  • a prolapse may become visible if the patient is asked to strain
    
    
• proctoscopy:
  • this is necessary to diagnose first or second degree piles
  • piles are seen as pink mucosal swellings bulging into the lumen as the proctoscope is withdrawn
    
    
• sigmoidoscopy:
  • this is indicated if there is a history of bleeding or there are symptoms that are suspicious of malignancy

National Institute for Health and Care Excellence (NICE) guidelines for suspected cancer should be followed, including the use of faecal immunochemical tests (FIT) and suspected cancer pathway referrals where appropriate. (1)

Meta-analysis of studies shows a positive predictive value of FIT of 10–28% for advanced colorectal neoplasm and 2.7–6.8% for early-onset colorectal cancer (2)

1. Quantitative faecal immunochemical testing to guide colorectal cancer pathway referral in primary care. NICE Diagnostics guidance [DG56]Published: 24 August 2023

2. Yeh J. et al. Performance of the Faecal Immunochemical Test in Detecting Advanced Colorectal Neoplasms and Colorectal Cancers in People Aged 40–49 Years: A Systematic Review and Meta-Analysis. Cancers (Basel). 2023 Jun; 15(11): 3006.