Your first stop for hemorrhoids is usually your primary care doctor. They can diagnose most hemorrhoids with a simple physical exam and start you on treatment the same day. If your symptoms don’t improve or your hemorrhoids are more advanced, you’ll be referred to a gastroenterologist or a colorectal surgeon depending on what you need.
Start With Your Primary Care Doctor
A primary care doctor can diagnose hemorrhoids based on your medical history, a description of your symptoms, and a physical exam. For external hemorrhoids, they’ll visually check the area around your anus for swelling, lumps, skin tags, or signs of a blood clot. For internal hemorrhoids, they’ll perform a digital rectal exam to feel for tenderness, bleeding, or abnormal masses.
If the digital exam isn’t conclusive, your doctor can perform an anoscopy right in the office. This is a quick, inexpensive procedure that doesn’t require sedation or any bowel prep. A small tube is inserted to give a direct view of the anal canal and lower rectum, which is usually enough to confirm internal hemorrhoids and assess how severe they are. Your doctor will also ask about your diet, toilet habits, and whether you use laxatives or enemas, since these all factor into both the diagnosis and the treatment plan.
Most hemorrhoids respond to conservative treatment: more fiber, more water, warm baths, and over-the-counter creams. Your primary care doctor can guide you through all of this. But if you’ve been managing symptoms at home for a few weeks without improvement, or if you’re dealing with persistent bleeding, pain, or tissue that bulges out of the anal canal, your doctor will refer you to a specialist.
When a Gastroenterologist Gets Involved
A gastroenterologist specializes in the entire digestive tract and is typically the next step when conservative treatment isn’t working. They’ll do a more thorough evaluation, which may include a flexible sigmoidoscopy or colonoscopy to look deeper into the rectum and lower colon. This is especially important if you have rectal bleeding, since the gastroenterologist needs to confirm that hemorrhoids are the actual source and rule out other conditions.
Gastroenterologists also perform minimally invasive, office-based procedures that can resolve hemorrhoids without surgery:
- Rubber band ligation: A tiny band is placed around the base of the hemorrhoid, cutting off its blood supply. The tissue shrinks and falls off within a few days. This is the most commonly performed office procedure for internal hemorrhoids and works well for mild to moderate cases.
- Infrared coagulation: A probe delivers heat to the hemorrhoid tissue, causing it to shrink. Patients tend to report less pain in the first 24 hours compared to banding.
- Sclerotherapy: A chemical solution is injected into the hemorrhoid to shrink it and reduce bleeding.
Professional guidelines from the American Society of Colon and Rectal Surgeons strongly recommend these office-based treatments for grade I and II hemorrhoids (those that bleed or bulge slightly but pull back in on their own) and for some grade III hemorrhoids (those that protrude and need to be pushed back in manually). A meta-analysis of 18 randomized trials found rubber band ligation to be superior to both sclerotherapy and infrared coagulation for grades I through III, making it the go-to option for most patients.
When You Need a Colorectal Surgeon
A colorectal surgeon is a specialist trained specifically in conditions of the colon, rectum, and anus. You’d see one when hemorrhoids are severe, keep coming back after office procedures, or involve complications like heavy bleeding or tissue that stays permanently outside the anal canal (grade IV). Your gastroenterologist or primary care doctor will make this referral.
Colorectal surgeons perform the same office-based procedures that gastroenterologists do, but they also offer surgical options for advanced cases:
- Hemorrhoidectomy: The hemorrhoid tissue is surgically removed. This is the most effective treatment for severe or prolapsed hemorrhoids. Recovery takes longer than office procedures, typically a few weeks, and post-operative pain can be significant, but recurrence rates are low.
- Stapled hemorrhoidopexy: Instead of removing the tissue, a surgical stapler repositions the hemorrhoid back into the anal canal and cuts off its blood supply. Recovery is generally faster and less painful than a traditional hemorrhoidectomy.
- Hemorrhoidal dearterialization: A Doppler-guided technique that locates the arteries feeding the hemorrhoid and ties them off. This is a newer, targeted approach with less post-operative discomfort.
A Cochrane review comparing rubber band ligation to surgical removal found that both approaches were equally effective for grade I and II hemorrhoids. For grade III hemorrhoids, surgery produced better results. Grade IV hemorrhoids, where tissue is constantly prolapsed or a blood clot has formed, almost always require a surgical approach.
How Hemorrhoid Grading Affects Your Path
Doctors classify internal hemorrhoids on a four-point scale based on how much tissue protrudes from the anal canal. This grading largely determines which provider you’ll end up seeing and what treatment you’ll receive.
Grade I hemorrhoids bleed but don’t prolapse. Grade II hemorrhoids prolapse during a bowel movement but slide back in on their own. Both of these are routinely managed by your primary care doctor or a gastroenterologist with conservative care or an office procedure. Grade III hemorrhoids protrude and need to be manually pushed back in. These sometimes respond to office procedures but may need surgical evaluation. Grade IV hemorrhoids are permanently prolapsed and can’t be pushed back in. Acutely thrombosed hemorrhoids (those with a painful blood clot) also fall into this category. These cases are best handled by a colorectal surgeon.
What About the Emergency Room
Most hemorrhoids don’t require emergency care, but there are two situations where you should go to an ER rather than waiting for a doctor’s appointment. The first is large amounts of rectal bleeding, especially if you feel lightheaded, dizzy, or faint. The second is a strangulated hemorrhoid, where the blood supply to an internal hemorrhoid gets cut off. This causes extreme pain and needs immediate attention.
A thrombosed external hemorrhoid (a hard, painful lump near the anus) is intensely uncomfortable but isn’t usually an emergency. If you can be seen by your primary care doctor or a surgeon within a day or two of symptoms starting, they can often drain the clot in the office with immediate relief. After 48 to 72 hours, the clot begins to resolve on its own, and draining becomes less beneficial.
Referrals and Insurance to Keep in Mind
Many insurance plans require a referral from your primary care doctor before you can see a gastroenterologist or colorectal surgeon. Even if your plan doesn’t strictly require one, starting with your primary care doctor is practical: they’ll confirm the diagnosis, try first-line treatment, and document that you need specialist care if it comes to that. This documentation can also help with insurance approval for procedures down the line. When you book a specialist appointment, bring your insurance card and any referral paperwork to avoid delays.