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C&P Exam Prep: Rectum and Anus (Hemorrhoids / Fissures)
DBQ Overview
Interview + Physical- Form Name
- rectum-and-anus
- Form Code
- rectum-and-anus
- Page Count
- 7
- Examiner Type
- Gastroenterologist or Physician
- Estimated Duration
- 15-30 minutes
- Exam Format
- Interview + Physical
What to Expect During Your Exam
Exam Overview
To document the current severity of your anorectal condition - including pruritus ani, hemorrhoids (internal or external), anal fissures, fistulas, abscesses, rectal prolapse, sphincter impairment, or stricture - in order to assign a disability rating under 38 CFR 4.114 (DC 7336 and/or DC 7337). The examiner will record your symptoms, treatment history, and physical findings to establish how your condition affects your daily functioning.
What the examiner evaluates:
- Type of anorectal condition (hemorrhoids internal/external, pruritus ani, fissure, fistula, abscess, rectal prolapse, stricture, sphincter impairment)
- Presence and frequency of bleeding or excoriation
- Presence, frequency, and reducibility of prolapse
- Number of thrombosis episodes per year
- Presence of anemia secondary to persistent bleeding (hemoglobin/hematocrit lab values)
- Pain during or after defecation
- Straining during defecation
- Luminal narrowing or stricture of the rectum or anus
- Impairment of sphincter control including incontinence
- Inability to open the anus or expel solid fecal matter
- Presence of drainage, discharge, or active abscess
- Current and prior treatments including dietary intervention, medications, procedures, and surgeries
- Impact on daily activities, occupational functioning, and quality of life
- Relevant diagnostic test results (CBC, colonoscopy, anoscopy, sigmoidoscopy)
The exam will include a verbal history/interview and a physical anorectal examination. The examiner will ask detailed questions about your symptoms and may perform a digital rectal exam or anoscopy. Bring all relevant medical records, prior treatment notes, and a list of current medications. You have the right to request that the exam be recorded in most states.
Typical duration: 15-30 minutes
Hemoglobin and Hematocrit (CBC)
Blood counts to identify anemia resulting from persistent rectal or hemorrhoidal bleeding. Critical for achieving the 20% rating under DC 7336.
What to expect:
A blood draw or review of recent lab work. The examiner will look for low hemoglobin or hematocrit values consistent with iron-deficiency anemia secondary to chronic blood loss.
Key thresholds:
- Hemoglobin below normal range (typically <12 g/dL in women, <13.5 g/dL in men) documented alongside persistent bleeding — Supports 20% rating under DC 7336 for hemorrhoids with persistent bleeding AND anemia
- Normal hemoglobin with persistent bleeding but no documented anemia — May not support 20% rating; rating would depend on prolapse and thrombosis frequency instead
Tips:
- Bring copies of recent CBC lab results to the exam, especially if they show low hemoglobin or hematocrit
- Mention if your doctor has discussed iron-deficiency anemia in the context of your rectal bleeding
- If you have been prescribed iron supplements due to bleeding, report this as it supports anemia finding
- Request lab work from your treating physician prior to the exam if you have persistent bleeding
Pain considerations: Anemia from blood loss may cause fatigue, shortness of breath, and weakness - clearly communicate these systemic symptoms if they affect your daily functioning.
Thrombosis Episode Frequency Count
The number of documented thrombosis (blood clot) episodes per year for hemorrhoids, which directly determines the rating percentage under DC 7336.
What to expect:
The examiner will ask you to recall and quantify how many times per year you have experienced a thrombotic episode - characterized by sudden severe anal pain, hard lump at the anus, and possible swelling.
Key thresholds:
- 3 or more thrombosis episodes per year (internal or external hemorrhoids) — Supports 20% rating for continuously prolapsed internal hemorrhoids OR 10% rating for external hemorrhoids with 3+ thrombosis episodes per year under DC 7336
- 2 or fewer thrombosis episodes per year with prolapsed internal hemorrhoids — Supports 10% rating under DC 7336
Tips:
- Keep a written log of thrombosis episodes with approximate dates and severity before your exam
- Review urgent care or ER visits, telehealth notes, or pharmacy records (e.g., Preparation H, sitz bath supplies) as corroborating evidence
- Do not underestimate frequency - report all episodes you have experienced over the past 12 months
- If episodes have worsened recently, note whether frequency has increased year over year
Pain considerations: Thrombosis episodes are typically extremely painful. Accurately describe the severity of pain during each episode, including whether you were unable to sit, work, or perform daily activities during the flare.
Physical Anorectal Examination
Direct visualization or palpation of external hemorrhoids, internal hemorrhoids (via anoscopy), anal fissures, fistulas, abscesses, prolapse, sphincter tone, and mucosal excoriation or bleeding.
What to expect:
The examiner may perform a visual inspection of the perianal area, a digital rectal examination, and/or anoscopy. You will likely be asked to assume a left lateral decubitus or knee-chest position. The exam assesses current anatomical findings.
Key thresholds:
- Visible excoriation or active bleeding noted on exam — Supports 10% rating under DC 7337 for pruritus ani with bleeding or excoriation
- Prolapsed hemorrhoids identified - assess whether spontaneously reducible, manually reducible, or irreducible — Irreducible or continuously prolapsed hemorrhoids support higher rating consideration under DC 7336
- Sphincter tone abnormality or impairment identified — May support rating for impairment of sphincter control under DC 7332 or as noted in DBQ
Tips:
- Do not use suppositories, creams, or enemas immediately before the exam - this may obscure findings
- If you are experiencing a flare on exam day, inform the examiner immediately
- If symptoms are absent on exam day but frequent at other times, clearly communicate this discrepancy to the examiner
- Inform the examiner if you have had prior anorectal procedures or surgeries and provide dates
Pain considerations: If the physical examination itself causes pain, clearly state your pain level (0-10 scale) during the procedure. Pain on examination supports the documented symptom severity.
Rating Criteria Breakdown
| Rating % | Criteria | Key Symptoms |
|---|---|---|
| 20% | Internal or external hemorrhoids with persistent bleeding AND anemia; OR continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis. |
CFR: Per DC 7336: 'Internal or external hemorrhoids with persistent bleeding and anemia; or continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis - 20%.' |
| 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. For DC 7337 (Pruritus Ani): With bleeding or excoriation - 10%. |
CFR: Per DC 7336: '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%.' Per DC 7337: 'Pruritus ani with bleeding or excoriation - 10%.' |
| 0% | Pruritus ani (anal itching) without bleeding or excoriation - noncompensable under DC 7337. Hemorrhoids that do not meet the thrombosis frequency or prolapse criteria - may also be noncompensable but should still be documented. |
CFR: Per DC 7337: 'Pruritus ani without bleeding or excoriation - 0%.' |
20% Internal or external hemorrhoids with persistent bleeding AN ...
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 requiring medical attention
- Documented anemia (low hemoglobin/hematocrit) attributable to hemorrhoidal blood loss
- Continuously prolapsed internal hemorrhoids that cannot be manually or spontaneously reduced
- Three or more distinct thrombosis episodes per year in continuously prolapsed internal hemorrhoids
- Significant fatigue, weakness, or shortness of breath secondary to anemia from bleeding
CFR: Per DC 7336: 'Internal or external hemorrhoids with persistent bleeding and anemia; or continuously prolapsed internal hemorrhoids with three or more episodes per year of thrombosis - 20%.'
10% Prolapsed internal hemorrhoids with two or fewer episodes pe ...
Prolapsed internal hemorrhoids with two or fewer episodes per year of thrombosis; OR external hemorrhoids with three or more episodes per year of thrombosis. For DC 7337 (Pruritus Ani): With bleeding or excoriation - 10%.
Key Symptoms
- Internal hemorrhoids that prolapse but reduce spontaneously or manually
- One to two thrombosis episodes per year in internal hemorrhoids
- External hemorrhoids with three or more painful thrombosis episodes per year
- Anal itching (pruritus ani) accompanied by visible bleeding or excoriation of the perianal skin
- Intermittent rectal discomfort, itching, and mild bleeding without anemia
CFR: Per DC 7336: '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%.' Per DC 7337: 'Pruritus ani with bleeding or excoriation - 10%.'
0% Pruritus ani (anal itching) without bleeding or excoriation ...
Pruritus ani (anal itching) without bleeding or excoriation - noncompensable under DC 7337. Hemorrhoids that do not meet the thrombosis frequency or prolapse criteria - may also be noncompensable but should still be documented.
Key Symptoms
- Anal itching without any visible bleeding or skin breakdown
- Hemorrhoids managed entirely by dietary intervention with no prolapse or thrombosis
- Mild intermittent discomfort without meeting threshold criteria for bleeding, anemia, or thrombosis frequency
CFR: Per DC 7337: 'Pruritus ani without bleeding or excoriation - 0%.'
How to Describe Your Symptoms
Bleeding
How to describe:
Describe the frequency, volume, color, and context of bleeding accurately. Specify whether bleeding occurs only with defecation, spontaneously, or continuously. Note whether blood is bright red on tissue or dripping into the toilet. Mention if it occurs daily, weekly, or with most bowel movements.
Worst-day example:
“On my worst days, I have bright red blood dripping into the toilet after every bowel movement and sometimes experience spontaneous spotting of blood in my underwear throughout the day. This has been happening multiple times a week for the past several months and I have been told by my doctor that my blood counts are low because of the ongoing blood loss.”
What the examiner listens for:
Persistent versus intermittent bleeding; whether bleeding is associated with anemia; frequency and volume of blood loss; whether treatment has been sought; any documented low hemoglobin or hematocrit values.
Understatements to avoid:
Do not say 'just a little blood on the paper' if the bleeding is frequent or has been discussed with your doctor. Do not minimize bleeding that your physician has already noted in records. Do not fail to mention if you have been diagnosed with or treated for anemia related to this bleeding.
Prolapse
How to describe:
Describe when prolapse occurs (with every bowel movement, with straining, spontaneously), whether the tissue returns on its own (spontaneously reducible), requires you to push it back manually (manually reducible), or remains outside permanently (irreducible). Be specific about how often this happens.
Worst-day example:
“On my worst days, tissue protrudes out of my rectum during and after every bowel movement and I have to manually push it back inside with my fingers. Sometimes it protrudes when I am just walking or standing for long periods. I deal with this almost every day and it causes me significant embarrassment, pain, and difficulty at work.”
What the examiner listens for:
Whether prolapse is continuous versus intermittent; whether it is self-reducing or requires manual reduction; frequency in relation to thrombosis episodes; impact on activities of daily living.
Understatements to avoid:
Do not describe intermittent prolapse as 'occasional' if it is occurring multiple times per week. Do not fail to mention that you must manually reduce the prolapse if that is the case - this detail is critical to the 10% versus 20% determination.
Thrombosis Episodes
How to describe:
A thrombosis episode is characterized by sudden severe anal pain, a hard tender lump at the anus, and difficulty sitting, walking, or working. Describe each episode clearly: when it started, how long it lasted, how severe the pain was, and whether you sought medical care or used over-the-counter treatment.
Worst-day example:
“During my worst thrombosis flare this past year, I had a hard, extremely painful lump at my anus that made it impossible for me to sit down for four days. The pain was a 9 out of 10. I could not drive to work, sit at my desk, or perform my normal duties. I have had this happen at least four times in the past twelve months.”
What the examiner listens for:
Specific number of distinct thrombosis episodes in the past 12 months; severity and duration of each episode; functional impact; any emergency or urgent care visits associated with episodes.
Understatements to avoid:
Do not round down the number of thrombosis episodes if you have experienced three or more. Do not describe a multi-day flare as a single episode without clarifying its duration. Do not fail to distinguish between general hemorrhoid discomfort and a true thrombotic episode.
Pruritus Ani (Anal Itching) and Excoriation
How to describe:
Describe the frequency, intensity, and character of the itching. Note whether the skin around the anus has cracked, bled, become raw, or developed visible sores or excoriation. Describe any impact on sleep, concentration, or daily activities.
Worst-day example:
“On my worst days, the itching around my anus is constant and intense enough to wake me up at night. The skin has become raw and cracked, and there is visible bleeding when I wipe. The itching and soreness distract me throughout the day and I have to leave meetings or work tasks to address it.”
What the examiner listens for:
Presence of visible excoriation or bleeding versus itching alone; impact on sleep and quality of life; whether topical treatments have been prescribed; frequency and chronicity of symptoms.
Understatements to avoid:
Do not say the itching is 'not a big deal' if it disrupts your sleep or daily activities. Do not fail to mention if your doctor has observed excoriation or skin breakdown during examinations. The 10% versus 0% distinction under DC 7337 hinges entirely on whether bleeding or excoriation is present.
Pain During Defecation
How to describe:
Describe pain severity on a 0-10 scale, duration of pain after defecation, and any resulting avoidance behaviors (e.g., holding bowel movements, which worsens constipation and symptoms). Note whether pain has caused you to use stool softeners, laxatives, or dietary modifications.
Worst-day example:
“On my worst days, defecation causes a sharp tearing pain rated 8 out of 10 that persists for one to two hours afterward. I dread going to the bathroom and sometimes avoid it for a full day, which makes the problem worse. The pain has caused me to leave work early and avoid physical activity.”
What the examiner listens for:
Severity and duration of pain with defecation; impact on dietary habits and bowel frequency; avoidance behaviors; use of prescribed pain-relieving treatments; any associated sphincter spasm.
Understatements to avoid:
Do not minimize procedural pain during defecation if it affects your schedule, diet, or daily routine. Do not fail to mention pain that persists for hours after a bowel movement, as this indicates more significant impairment.
Functional Impact and Daily Life
How to describe:
Connect your anorectal symptoms to specific limitations in work, social functioning, and activities of daily living. Describe any modifications you have made such as dietary changes, avoidance of prolonged sitting, carrying supplies (wipes, pads), or needing restroom access. Include impact on occupational duties.
Worst-day example:
“On my worst days, I cannot sit comfortably for more than 20 minutes at a time, which affects my ability to drive, work at a desk, or attend events. I carry protective pads because of unpredictable discharge and bleeding. I have had to leave work early multiple times due to pain and bleeding, and I avoid social situations out of embarrassment.”
What the examiner listens for:
Specific work-related limitations; frequency of missed work or modified duties; need for assistive measures such as cushions, pads, or frequent restroom access; impact on physical activity, social life, and mental health.
Understatements to avoid:
Do not give only a clinical description of your symptoms without connecting them to real-life impact. The DBQ specifically asks for functional impact - be prepared to give concrete examples of limitations caused by this condition.
Common Mistakes to Avoid
Underreporting thrombosis frequency by combining multiple-day flares into one 'episode'
The 10% versus 20% distinction for hemorrhoids under DC 7336 depends critically on whether you have had 3 or more distinct thrombosis episodes per year. Undercounting can cost you the higher rating.
Instead: Count each distinct thrombosis event (new hard painful lump, separate from the prior one that resolved) as a separate episode. Keep a written log with approximate dates before your exam.
Impact: 10% vs 20%
Not bringing recent CBC lab results showing low hemoglobin or hematocrit
The 20% rating for hemorrhoids requires both persistent bleeding AND anemia. Without objective lab documentation, the examiner may not be able to check the anemia box on the DBQ even if you report significant bleeding.
Instead: Request a recent CBC from your VA or private physician before the exam. Bring the printed results and highlight hemoglobin and hematocrit values. If your doctor has diagnosed iron-deficiency anemia, bring those records as well.
Impact: 20%
Describing pruritus ani symptoms as 'just itching' without mentioning excoriation or bleeding
Under DC 7337, pruritus ani without bleeding or excoriation is rated 0% - noncompensable. The 10% rating requires documented bleeding or excoriation. Veterans often minimize skin breakdown as unimportant.
Instead: Explicitly describe any cracking, bleeding, raw skin, or visible skin breakdown around the anus. If your treating physician has noted excoriation in records, bring those notes to the exam.
Impact: 0% vs 10%
Not describing the type and reducibility of prolapse accurately
The difference between a spontaneously reducible, manually reducible, and irreducible (persistent) prolapse directly affects the rating level. Examiners need this detail to correctly complete the DBQ prolapse fields.
Instead: Before the exam, clearly establish in your mind whether your prolapse reduces on its own, requires manual reduction, or is permanent. Practice describing this clearly: 'The tissue comes out with every bowel movement and I have to push it back with my fingers.'
Impact: 10% vs 20%
Reporting only how you feel on exam day rather than your typical or worst symptoms
Anorectal conditions fluctuate. If you happen to be in a quiet period on exam day, the examiner's findings may not reflect your actual disability level. VA ratings should reflect the full picture of your condition, including flares.
Instead: Per M21-1 guidance, report your worst-day symptoms and typical functioning over the past 12 months. If today is a good day, say so explicitly: 'Today is relatively mild, but typically I experience...' and describe your average and worst symptom days.
Impact: All levels
Failing to mention all treatment modalities, including dietary changes and OTC treatments
The DBQ asks about all treatments including special diet, medications, and procedures. Treatment burden (daily stool softeners, high-fiber diet requirements, sitz baths, prescription creams, rubber band ligation, surgery) demonstrates severity and ongoing management need.
Instead: Prepare a complete list of all treatments: fiber supplements, stool softeners, prescribed creams or suppositories, sitz baths, rubber band ligation, sclerotherapy, or surgery. Include dates of procedures and whether symptoms persisted afterward.
Impact: All levels
Not connecting symptoms to functional limitations for the examiner
The DBQ includes a section on functional impact. If you only describe clinical symptoms without explaining how they limit your work, sleep, mobility, or daily activities, the examiner has less documentation to support a meaningful rating.
Instead: For every symptom, prepare a real-world impact statement: 'Because of the prolapse, I cannot sit for more than 30 minutes'; 'Because of the bleeding, I carry pads and have had to leave work early.' Connect symptoms to life limitations.
Impact: All levels
Prep Checklist
Before Your Exam
Day Of
During the Exam
After the Exam
Your Rights During a C&P Exam
- You have the right to request that your C&P examination be recorded in most states. Notify the examiner at the start of the exam and bring a recording device.
- You have the right to have a VSO representative, accredited claims agent, or attorney assist you in preparing for your C&P examination.
- You have the right to request a copy of the completed DBQ after your examination through My HealtheVet, a FOIA request, or your VSO.
- You have the right to submit your own independent medical opinion (nexus letter) from a private treating physician if you believe the C&P examiner's opinion is inadequate or incorrect.
- You have the right to request a new C&P examination if the original examination was inadequate, the examiner did not review relevant records, or the DBQ contains factual errors about your reported symptoms.
- You have the right to submit a Notice of Disagreement (NOD) if you disagree with the rating decision following the C&P exam. You have one year from the date of the rating decision to file.
- You have the right to be treated with dignity and respect during the physical examination. If you are uncomfortable with any aspect of the examination, you may request a same-sex examiner or to have a support person present.
- You have the right to have all relevant medical evidence - including private treatment records, lab results, and buddy statements - reviewed by the examiner before the DBQ is completed.
- The VA has a duty to assist you in obtaining relevant records, including private medical records if you authorize release with VA Form 21-4142.
- You are not required to exaggerate your symptoms - you are entitled only to accurately and completely describe your condition on your worst days, your average days, and the full impact on your daily functioning.
Related Conditions
- Anorectal / Perianal Fistula Fistulas are evaluated on the same Rectum and Anus DBQ and may be separately ratable. Fistulas can develop secondary to anorectal abscesses, Crohn's disease, or trauma. The DBQ includes specific fields for fistula with drainage, pain, and abscess.
- Anorectal / Perianal Abscess Abscesses are covered on the same DBQ. They may occur secondary to hemorrhoids, fissures, or fistulas. Recurrent abscesses with drainage can support higher ratings and may be evaluated separately or as part of a combined anorectal condition rating.
- Rectal Prolapse Rectal prolapse is documented on the same DBQ under separate fields from hemorrhoidal prolapse. The degree of prolapse (spontaneously reducible, manually reducible, or irreducible) and associated symptoms inform the overall anorectal rating.
- Impairment of Sphincter Control Sphincter impairment (fecal incontinence) may result from chronic hemorrhoids, surgical complications, or fissures. It is documented on the same DBQ and may be evaluated under DC 7332 for separate rating consideration if significant.
- Anal Stricture / Rectal Stricture Stricture of the anus or rectum can occur as a complication of surgery, chronic fissures, or radiation therapy. It is documented on the same DBQ and may be ratable under DC 7335 with luminal narrowing causing obstruction.
- Irritable Bowel Syndrome (IBS) IBS frequently co occurs with anorectal conditions and can contribute to chronic constipation or diarrhea that aggravates hemorrhoids and fissures. IBS may be separately service connected and rated under DC 7319.
- Inflammatory Bowel Disease (Crohn's Disease / Ulcerative Colitis) Crohn's disease and ulcerative colitis commonly cause anorectal manifestations including fissures, fistulas, abscesses, and perianal disease. These conditions are rated separately under DC 7323 (ulcerative colitis) or DC 7326 (Crohn's disease) and may serve as the underlying etiology for secondary anorectal conditions.
- Iron Deficiency Anemia Persistent hemorrhoidal bleeding can cause secondary iron deficiency anemia, which is a required component of the 20% rating under DC 7336. If separately documented and ratable, anemia may support additional secondary service connection under DC 7700.
- Dyssynergic Defecation / Levator Ani Syndrome Pelvic floor dysfunction including levator ani syndrome and dyssynergic defecation can cause or worsen hemorrhoids, fissures, and constipation. The DBQ includes a specific checkbox for this condition and it may be separately ratable.
- Anismus / Functional Constipation Chronic constipation from anismus or functional defecation disorders strains the anorectal region and can aggravate hemorrhoids and fissures. It is documented on the same DBQ and may warrant separate evaluation under the digestive system.
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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.