Hemorrhoids: the Emperor of many diagnostic delays

In a rush clinical practice when a patient speaks about symptoms located in the anal area such as pain, pruritus or bleeding, is not common to do a visual inspection or a digital rectal examination in the first instance, for two reasons: the prevalence of a”benign” diagnosis is higher than the one for malignant tumours, and also this area seems to be more for a surgeon than for a General Practitioner.

Symptoms associated with anorectal cancer are bleeding (half of the cases), pain, anal pruritus and constipation, but a high percentage can be also asymptomatic. Another diagnostic difficulty is that these symptoms are also present in several non-malignant conditions such as hemorrhoids and anal fistula or fissure. When after the anamnesis we have to think in the different clinical options probably our mind relates bleeding with hemorrhoids and cancer, pain with fistula, pruritus with a non-malignant diagnosis and constipation with cancer, but what we see in the clinical practice is that anamnesis is not enough in general and less in the anorectal area. A complete physical examination and visual inspection is mandatory.