By S. Ellesmore, A. C. J. Windsor (auth.), Mr Charles V. Mann MA, MCh, FRCS (eds.)

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Accurate answers to these questions must be obtained before any management is decided. The circumferential extent of haemorrhoids and the difficulties this may cause for treatment is often ignored. It is frequently taken for granted that the diagnosis of haemorrhoids is easy. Two assumptions underlie this view - one, that a patient complaining of bleeding on defaecation, especially one below thirty years of age, is virtually certain to be suffering from haemorrhoids, and two, that the diagnosis does not need to be confirmed by a meticulous process of examination that is designed to exclude other (and often much more serious) conditions; both are wrong.

Before removing the finger, which must also be done gently, the patient should be asked to squeeze the finger (which is a further check on the muscle tone of the external sphincter muscle) and strain down (which can confirm that the anal sphincter is weak). If the straining effort is continued as the index finger is withdrawn, haemorrhoids (or other lesions) may follow it, and highlight that they are second-degree. After removal, the finger is examined for any telltale evidence of blood, pus or mucus indicative of other pathology.

These may be unassociated with specific pathological conditions but may be due to Crohn's disease, tuberculosis and, rarely, a neoplasm. Sphincter tone. A tightly closed anus may indicate spasm due to a fissure. A patulous anus may be caused by anal intercourse or be the consequence of age. Altered sphincter tone may have important consequences for treatment. A haemorrhoid is a bluish-red cushion of tissue, covered by smooth mucosa which is usually reddest at its upper (internal) origin above the dentate line.

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