DC 7336 · 38 CFR 4.114
Rectum and Anus (Hemorrhoids / Fissures) C&P Exam Prep
To document the current severity of hemorrhoids, fissures, and related anorectal conditions in order to assign a disability rating under 38 CFR 4.114, DC 7336. The examiner will evaluate the type (internal vs. external), frequency of thrombotic episodes, presence of bleeding, prolapse characteristics, and associated complications such as anemia or sphincter impairment.
- Format:
- Interview + Physical
- Typical duration:
- 15-30 minutes
- DBQ form:
- rectum-and-anus (rectum-and-anus)
- Examiner:
- Gastroenterologist or Physician
What the examiner evaluates
- Type of hemorrhoids: internal, external, or both
- Frequency of thrombotic episodes per year
- Whether hemorrhoids are prolapsed and reducibility status
- Presence and persistence of rectal bleeding
- Presence of anemia secondary to bleeding (hemoglobin/hematocrit values)
- Pain during or after defecation
- Straining during defecation
- Luminal narrowing or rectal/anal stricture
- Impairment of sphincter control
- Presence of drainage, abscess, or fistula
- Current treatments including dietary intervention, medications, or surgical history
- Functional impact of the condition on daily activities and occupation
- Associated diagnoses such as pruritus ani, rectal prolapse, fissures, or fistulas
The exam will involve a medical history interview and a physical examination of the anorectal region. You should expect a visual and potentially digital rectal examination. The examiner may ask you to strain as if defecating to assess for prolapse. Bring a list of all current medications and any relevant lab work such as CBC results showing hemoglobin or hematocrit values.
Measurements and tests
Hemoglobin and Hematocrit (CBC)
What it measures: Red blood cell mass; used to determine whether persistent rectal bleeding has caused anemia, which is a key criterion for the 20% rating under DC 7336.
What to expect: The examiner may review existing lab results or order a CBC. Normal hemoglobin is approximately 13.5-17.5 g/dL for men and 12.0-15.5 g/dL for women. Values below normal range may indicate anemia secondary to hemorrhoidal bleeding.
Critical thresholds
- Hemoglobin below normal range with documented persistent bleeding Supports 20% rating under DC 7336 (internal or external hemorrhoids with persistent bleeding and anemia)
Tips
- Bring copies of any recent CBC lab results to the exam
- If you have been treated for anemia (iron supplements, dietary changes), tell the examiner
- Mention if you have noticed pale stools, fatigue, dizziness, or shortness of breath consistent with anemia
- If you have deferred getting labs due to access issues, mention this so the examiner can order them
Pain considerations: Anemia-related fatigue and weakness can significantly limit your functional capacity. Accurately report any fatigue, weakness, or dizziness that limits your daily activities.
Visual and Digital Rectal Examination
What it measures: External appearance of the anal region including visible hemorrhoids, fissures, skin tags, excoriation, prolapse, and sphincter tone. Internal examination assesses sphincter control, prolapse reducibility, and luminal narrowing.
What to expect: The examiner will visually inspect the perianal area and may perform a digital rectal exam. You may be asked to bear down or strain. The examiner will note whether hemorrhoids prolapse and whether they reduce spontaneously, with manual assistance, or are irreducible.
Critical thresholds
- Persistently prolapsed internal hemorrhoids (irreducible) with 3+ thrombotic episodes per year Supports 20% rating under DC 7336
- Prolapsed internal hemorrhoids with 2 or fewer thrombotic episodes per year, OR external hemorrhoids with 3+ thrombotic episodes per year Supports 10% rating under DC 7336
Tips
- Do not apply topical treatments the morning of the exam that might reduce visible inflammation unless medically necessary
- If you typically have more symptoms after prolonged sitting or after a bowel movement, communicate this timing to the examiner
- Be honest about whether hemorrhoids reduce on their own, require manual reduction, or remain prolapsed
- If you have photos or prior procedural reports documenting prolapse, bring them
Pain considerations: Report any pain during the examination accurately. Pain with defecation, pain at rest, and pain with prolonged sitting are all relevant to functional impairment documentation.
Rating criteria by percentage
20%
Internal or external hemorrhoids with persistent bleeding and anemia; OR continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis.
Key symptoms
- Persistent rectal bleeding documented over time
- Anemia confirmed by laboratory values (low hemoglobin or hematocrit)
- Internal hemorrhoids that remain continuously prolapsed
- Three or more distinct thrombotic episodes annually
- Significant pain, inability to sit comfortably, or disruption of daily activities
From 38 CFR: 'Internal or external hemorrhoids with persistent bleeding and anemia; or continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis 20' (38 CFR 4.114, DC 7336)
10%
Prolapsed internal hemorrhoids with two or fewer episodes per year of thrombosis; OR external hemorrhoids with three or more episodes per year of thrombosis.
Key symptoms
- Internal hemorrhoids that prolapse but reduce spontaneously or manually
- One to two thrombotic episodes per year for internal hemorrhoids
- Three or more thrombotic episodes per year for external hemorrhoids
- Intermittent rectal bleeding without documented anemia
- Pain with defecation
- Straining with bowel movements
- Recurrent swelling and discomfort
From 38 CFR: 'Prolapsed internal hemorrhoids with two or less episodes per year of thrombosis; or external hemorrhoids with three or more episodes per year of thrombosis 10' (38 CFR 4.114, DC 7336)
Describing your symptoms accurately
Thrombotic Episodes
How to describe it: Be specific about how many distinct episodes of thrombosis you experience per year. A thrombotic episode involves sudden, severe anal pain with a tender, firm lump at the anus caused by a blood clot forming inside the hemorrhoid. Describe onset, duration, severity, and how each episode affected your ability to work, sit, or perform daily activities.
Example: During my worst episodes, I experience sudden, severe anal pain that I rate 8 out of 10. The pain makes it impossible to sit for more than a few minutes, prevents me from driving, and disrupts my sleep. Each episode lasts approximately 5 to 10 days. I have had four such episodes in the past 12 months.
Examiner listens for: Number of distinct thrombotic episodes per year (key threshold is 3 or more for 10% external or 20% internal prolapsed), duration of each episode, impact on function, and whether episodes required medical treatment or emergency care.
Avoid: Do not say 'I just have some occasional hemorrhoid flare-ups' without specifying the number of thrombotic episodes. The rating thresholds depend on exact episode counts, so vague descriptions may result in an underrating.
Prolapse
How to describe it: Clearly describe whether your internal hemorrhoids prolapse (protrude outside the anal canal), and if so, whether they go back in on their own, require you to push them back manually, or remain permanently prolapsed. Describe when prolapse occurs - with bowel movements, physical activity, prolonged sitting, or spontaneously.
Example: My hemorrhoids frequently prolapse during bowel movements and sometimes while I am walking or sitting for extended periods. I have to manually push them back in after most bowel movements, which is painful and takes several minutes. On my worst days they remain prolapsed for hours regardless of what I do.
Examiner listens for: Whether prolapse is spontaneously reducible, manually reducible, or persistently irreducible; frequency of prolapse; circumstances triggering prolapse; and impact on hygiene and daily function.
Avoid: Do not describe manual reduction as 'they usually go back in fine.' Specify that manual reduction is required and describe the pain and difficulty involved.
Rectal Bleeding
How to describe it: Describe the frequency, volume, and duration of rectal bleeding. Note whether bleeding occurs with every bowel movement, only occasionally, or continuously. Describe what the blood looks like (bright red on toilet paper, dripping into the toilet, or mixed with stool) and how long episodes of bleeding last. Mention any steps you have taken such as iron supplementation due to blood loss.
Example: On my worst days I have bright red bleeding with every bowel movement. The blood drips into the toilet and soaks through toilet paper. I have had periods lasting several weeks where this occurs daily, requiring me to wear a pad. My doctor placed me on iron supplements because my blood counts dropped.
Examiner listens for: Persistent vs. intermittent bleeding, evidence of anemia through lab values, impact on quality of life, and whether the severity meets the threshold for the 20% rating (persistent bleeding with anemia).
Avoid: Do not minimize bleeding by saying 'just a little spotting sometimes.' Accurately convey the duration and frequency. If you have had periods of persistent daily bleeding, state this clearly.
Pain with Defecation
How to describe it: Describe whether you experience pain before, during, or after bowel movements. Rate the pain on a 0-10 scale. Explain how pain affects your ability to have timely bowel movements, whether you avoid defecating due to pain (which can worsen constipation), and how long post-defecation pain lasts.
Example: During my worst days the pain during bowel movements is a 9 out of 10. The pain is sharp and burning and continues for one to two hours afterward. I find myself delaying bowel movements because of the anticipated pain, which then causes constipation and worsens the hemorrhoids. Sitting on hard surfaces is intolerable for the rest of the day.
Examiner listens for: Severity of pain, functional consequences of pain-avoidance behavior, impact on diet and bowel habits, and whether pain is associated with fissures in addition to hemorrhoids.
Avoid: Do not describe post-defecation pain as 'a little uncomfortable.' Use specific pain scale ratings and describe the duration and functional consequences accurately.
Functional and Occupational Impact
How to describe it: Describe how your condition limits your ability to sit for extended periods, perform physical labor, maintain work attendance, drive, exercise, and engage in social activities. Mention any accommodations you require at work such as standing desks, frequent bathroom breaks, or inability to perform jobs requiring prolonged sitting or heavy lifting.
Example: During flare-ups I cannot sit in a standard chair for more than 15 minutes without severe pain. I have missed work days during thrombotic episodes. I cannot perform activities requiring prolonged sitting such as driving long distances, attending meetings, or working at a desk. I use a donut cushion daily to manage baseline discomfort.
Examiner listens for: Specific functional limitations tied to the anorectal condition, occupational impact, and how frequently these limitations occur.
Avoid: Do not say 'it does not really affect my work much' if you have made adaptations or accommodations. Adaptations themselves indicate functional impairment.
Sphincter Impairment and Fecal Leakage
How to describe it: If you experience any loss of sphincter control, fecal urgency, accidental leakage, or inability to control gas, describe the frequency and circumstances. Note whether this has affected your social activities, work, or ability to be away from a bathroom for extended periods.
Example: I experience fecal urgency several times per week where I must reach a bathroom within minutes or risk an accident. I have had episodes of fecal leakage that required me to wear protective undergarments. This has significantly limited my social activities and travel.
Examiner listens for: Evidence of sphincter impairment that may support higher disability ratings or secondary conditions, frequency of urgency or incontinence, and social or occupational impact.
Avoid: Do not omit sphincter control problems out of embarrassment. This is medically significant information that can affect your rating.
Common mistakes to avoid
Not tracking and reporting the exact number of thrombotic episodes per year
Why: The rating thresholds under DC 7336 are specifically tied to whether you have fewer than 3 or 3 or more thrombotic episodes per year. Without an accurate count, the examiner may default to the lower rating level.
Do this instead: Keep a symptom diary and come to the exam with a documented count of thrombotic episodes over the past 12 months. Be prepared to describe each episode including onset, duration, severity, and treatment sought.
Impact: Determines 10% vs. 20% for both internal and external hemorrhoids
Describing symptoms only on a typical day rather than on worst days
Why: VA rating is based on the full range of your condition per M21-1 guidance, including worst-day presentations. Describing only average days may result in a rating that does not capture your actual disability level.
Do this instead: Explicitly describe your worst days in detail, including pain severity on a 0-10 scale, specific functional limitations, and how frequently you experience your worst-day symptoms.
Impact: All rating levels
Not mentioning anemia or bringing lab work
Why: The 20% rating requires documented persistent bleeding AND anemia. If you do not mention anemia or provide laboratory values, the examiner may not order the necessary tests or may not check this critical box on the DBQ.
Do this instead: Bring recent CBC lab results to the exam. If you have been treated for anemia (iron supplements, B12, dietary changes), mention this explicitly. If you have not had recent labs, ask the examiner to order them.
Impact: 20% rating (persistent bleeding with anemia)
Failing to describe prolapse type and reducibility accurately
Why: The rating criteria distinguish between spontaneously reducible, manually reducible, and persistently irreducible (continuous) prolapse. Continuous irreducible prolapse with 3+ thrombotic episodes supports the 20% rating. Saying 'they go back in' without clarifying whether this is spontaneous or manual underrepresents your condition.
Do this instead: Clearly state whether prolapsed hemorrhoids require you to manually push them back in, whether they ever remain prolapsed for extended periods, and whether they have become irreducible.
Impact: 10% vs. 20% rating
Minimizing pain and functional limitations out of stoicism
Why: Examiners can only document what you report. Understating pain or functional limitations results in a DBQ that does not accurately reflect your disability and may lead to a lower rating.
Do this instead: Report your symptoms accurately and completely. Use specific pain scale ratings, describe duration of pain episodes, and explain how symptoms affect your ability to sit, work, drive, and perform daily activities.
Impact: All rating levels
Not mentioning associated conditions such as fissures, fistulas, or pruritus ani
Why: These conditions may be separately ratable under their own diagnostic codes (e.g., DC 7337 for pruritus ani) and may contribute to your overall combined disability rating. Failing to mention them means they may not be evaluated or service-connected.
Do this instead: Report all anorectal symptoms to the examiner including anal itching, fissures, fistulas, abscesses, or drainage. Ask that each condition be separately addressed in the DBQ.
Impact: Separate ratings under DC 7337 and related codes
Discussing only current symptoms without describing the history and progression of the condition
Why: The DBQ includes a field for history including onset and course of the condition. A complete history supports the nexus between your condition and service and helps document that the condition is chronic rather than episodic.
Do this instead: Be prepared to describe when you first noticed symptoms, how the condition has progressed, what treatments you have tried, and how the severity has changed over time.
Impact: Service connection and all rating levels
Prep checklist
- critical
Document exact number of thrombotic episodes in the past 12 months
Review your medical records, pharmacy receipts, and any personal notes to count the number of distinct thrombotic episodes you experienced in the last year. Each episode should be documented with approximate dates, duration, and severity. This is the most critical data point under DC 7336.
before exam
- critical
Gather recent CBC laboratory results
Obtain copies of any complete blood count results from the past 6-12 months. Look for hemoglobin and hematocrit values. Low values support the anemia criterion required for the 20% rating. If you do not have recent labs, ask your primary care provider to order them before the exam.
before exam
- critical
Compile complete treatment history
List all treatments you have used or are currently using including dietary fiber supplements, stool softeners, topical creams, sitz baths, rubber band ligation, sclerotherapy, surgical hemorrhoidectomy, or other procedures. Note dates of surgeries and outcomes.
before exam
- critical
Write out a symptom narrative including worst-day descriptions
Write a clear description of your symptoms including bleeding frequency and severity, prolapse characteristics and reducibility, pain during and after defecation, thrombotic episode history, sphincter control issues, and functional limitations. Include both typical-day and worst-day descriptions.
before exam
- recommended
Request and review your service treatment records and VA records
Review your STRs and VA treatment records for any documentation of hemorrhoids, rectal symptoms, or related conditions during or after service. Identify the earliest documented evidence of your condition to support the service connection timeline.
before exam
- recommended
Prepare a list of all current medications
List all medications taken for your anorectal condition including prescription and over-the-counter items. Include dosages, frequency, and the prescribing provider if applicable. The DBQ specifically asks about prescribed medications.
before exam
- recommended
Note any associated conditions for separate evaluation
Document any associated conditions such as anal fissures, pruritus ani (anal itching), rectal prolapse, anal fistulas, or abscesses. These may be separately ratable and should be mentioned to the examiner.
before exam
- optional
Check your state's exam recording law
In most states veterans have the right to record their C&P examination. Research your state's one-party or two-party consent laws and notify the examiner at the start of the exam if you intend to record. Recording provides an accurate record of what was discussed.
before exam
- recommended
Do not apply anesthetic topical treatments that morning unless medically necessary
Some topical hemorrhoid treatments containing lidocaine or similar agents may temporarily reduce visible inflammation or discomfort. Unless medically required, avoid applying these immediately before the exam so the examiner can accurately assess your baseline condition.
day of
- critical
Arrive with written symptom notes and bring all supporting documents
Bring your written symptom narrative, lab results, medication list, treatment history, and any procedural reports. Do not rely on memory alone during the exam, as the 15-30 minute window is short.
day of
- recommended
Be prepared for a physical examination
Wear comfortable, loose-fitting clothing. You will likely need to disrobe from the waist down for the physical examination. You may be asked to lie on your side in the lateral decubitus position or to stand and bear down. The examination itself is typically brief.
day of
- critical
Report symptoms on your worst day, not just a typical day
When the examiner asks how you are doing, describe your worst-day symptoms specifically. Use language such as 'On my worst days, which occur [frequency]...' to ensure the full severity of your condition is documented.
during exam
- critical
State the exact number of thrombotic episodes per year explicitly
Do not wait for the examiner to ask about frequency. Proactively state the number of thrombotic episodes you have had in the past 12 months and describe each one briefly. This is the primary rating driver under DC 7336.
during exam
- critical
Describe prolapse type, frequency, and reducibility clearly
If your hemorrhoids prolapse, tell the examiner whether they return spontaneously, require manual reduction, or remain persistently prolapsed. Be specific about how often prolapse occurs and under what circumstances.
during exam
- critical
Mention anemia, fatigue, and systemic symptoms of blood loss
If you have experienced fatigue, weakness, dizziness, pallor, or shortness of breath that your provider attributed to anemia from rectal bleeding, state this explicitly. Ask the examiner to document the relationship between your bleeding and anemia.
during exam
- recommended
Describe the functional impact on work and daily life
Tell the examiner specifically how your condition limits your ability to sit for extended periods, perform physical activity, maintain work attendance, drive, or engage in social activities. Be concrete and specific.
during exam
- recommended
Report all associated anorectal symptoms
Mention anal itching (pruritus ani), fissures, fistulas, drainage, abscesses, sphincter control problems, or any other anorectal symptoms even if you believe they are minor. Each may be separately ratable.
during exam
- recommended
Write down what was discussed immediately after the exam
As soon as possible after the exam, write down what questions were asked, what you reported, and any observations the examiner made. This record is valuable if you need to appeal a rating decision.
after exam
- recommended
Request a copy of the completed DBQ
You have the right to request a copy of the completed DBQ through your VSO, MyHealtheVet, or through a FOIA request. Review it for accuracy once it becomes available in your eFolder.
after exam
- recommended
Contact your VSO if the exam was inadequate
If the examiner did not perform a physical examination, did not ask about thrombotic episode frequency, or did not address your primary symptoms, contact your VSO or accredited claims agent immediately. An inadequate exam can be challenged.
after exam
Your rights during a C&P exam
- You have the right to an adequate C&P examination that addresses all claimed conditions and symptoms. If the examiner does not perform a physical examination or does not ask about the key rating criteria under DC 7336 (thrombotic episodes, prolapse, bleeding, anemia), the examination may be considered inadequate and can be challenged.
- You have the right to submit a buddy statement or personal statement describing your symptoms if you believe the examiner's report does not accurately reflect what you reported during the exam.
- In most states you have the right to record your C&P examination. Check your state's recording consent laws and notify the examiner at the start of the exam if you intend to record.
- You have the right to request a copy of the completed DBQ form through your eFolder on VA.gov, through MyHealtheVet, or through your Veterans Service Organization.
- You have the right to a Supplemental Claim or appeal if you believe the rating decision did not accurately reflect the severity of your condition as documented in the DBQ or your medical records.
- You have the right to submit independent medical evidence including private medical opinions, specialist evaluations, or Nexus letters in support of your claim.
- You have the right to have a VSO, accredited claims agent, or attorney represent you in your claim at no cost through accredited VSO representation.
- You have the right to request that the VA order additional testing such as a CBC to document anemia if this was not performed during the examination and is relevant to your rating.
- You have the right to be treated with dignity and respect during your C&P examination. If you feel the examiner was dismissive, did not listen to your symptoms, or did not perform an adequate evaluation, document this and report it to your VSO.
- You have the right to review your entire claims file (C-file) by submitting a FOIA request to your VA Regional Office.
Related conditions
- Pruritus Ani (Anal Itching) DC 7337 rates anal itching separately from hemorrhoids. Rated at 10% with bleeding or excoriation and 0% without. If you experience persistent anal itching associated with or secondary to your hemorrhoids or fissures, this may be separately ratable and should be reported to the examiner.
- Rectal Prolapse Rectal prolapse involves the protrusion of the rectal wall through the anal opening and is evaluated separately from hemorrhoidal prolapse. If you have been diagnosed with rectal prolapse in addition to or secondary to hemorrhoids, ensure the examiner addresses it as a distinct finding on the DBQ.
- Anal Fissure Anal fissures are tears in the lining of the anal canal that cause sharp pain and bleeding with defecation. They frequently coexist with hemorrhoids and may be rated separately. Ensure the examiner documents any fissures on the DBQ and evaluates them as a distinct diagnosis.
- Anorectal or Perianal Fistula Fistulas are abnormal connections between the rectum or anus and surrounding tissue. They may develop as complications of abscesses and may be ratable under DC 7330 (Intestinal fistulous disease, external) at up to 100%. If you have been diagnosed with a fistula, ensure this is separately addressed.
- Anorectal or Perianal Abscess Abscesses in the perianal region may develop secondary to hemorrhoids or fissures and may cause significant pain and drainage. If you have had or currently have an abscess, this should be documented on the DBQ as it affects the severity assessment.
- Iron Deficiency Anemia (Secondary to Hemorrhoids) If chronic hemorrhoidal bleeding has caused iron deficiency anemia, anemia may be separately ratable as a secondary condition. Documenting the causal relationship between hemorrhoidal bleeding and anemia is critical both for the 20% rating under DC 7336 and for potential secondary service connection of the anemia itself.
- Irritable Bowel Syndrome (IBS) IBS frequently coexists with hemorrhoids and anal fissures due to alternating constipation and diarrhea that worsens anorectal conditions. If you have been diagnosed with IBS, it may be separately ratable and may also serve as a basis for secondary connection to your hemorrhoid condition.
- Dyssynergic Defecation (Levator Ani / Anismus) Pelvic floor dysfunction including dyssynergic defecation or levator ani syndrome can cause or worsen hemorrhoids and fissures. The DBQ specifically includes a checkbox for this condition. If diagnosed, ensure it is documented by the examiner.
Get a personalized prep packet
This guide covers what to expect for any veteran with this condition. If you have already uploaded your medical records, sign in to generate a packet that maps your specific symptoms to the DBQ fields your examiner will fill out.
This C&P exam preparation guide is for educational purposes only and does not constitute legal, medical, or claims advice. Always consult with a qualified Veterans Service Organization (VSO) representative or VA-accredited attorney for guidance specific to your claim. Never exaggerate, minimize, or fabricate symptoms during a C&P examination.