Hemorrhoids remain one of the most common colorectal complaints. Objectively, hemorrhoids are a pathological engorgement of the submucosal vascular plexus in the anal canal. They are often asymptomatic and innocent bystanders. Symptomatic hemorrhoids may result in bleeding, prolapse, and, less commonly, pain. This chapter outlines the differential diagnosis and the basis for a thoughtful evaluation and assessment of patients with “hemorrhoid” symptoms. We highlight the relatively rare situations that require urgent management or referral to a surgical intervention. More commonly, however, patients may require preliminary counseling, initiation of conservative measures, and referral to colorectal specialists for consideration of office interventions or surgical procedures. Decision-making depends on the individual constellation and severity of symptoms, objective findings, and expectations and goals. Special circumstances (immunosuppression, pregnancy, inflammatory bowel disease, liver disease, prior radiation) need to be taken into consideration.