A patient arrives at your office with a chief complaint of hemorrhoids. Is it really hemorrhoids, or is it something else? How are hemorrhoids best treated? And when should you send the patient to see a surgeon? Hemorrhoids have plagued humankind since ancient times and might have even influenced world history. The emperor of France, Napoleon Bonaparte, suffered from hemorrhoidal disease. On the day of the decisive battle at Waterloo, Napoleon was in pain because of a severe case of thrombosed hemorrhoids, which impaired his battlefield conduct.1 Today hemorrhoids remain the most common anorectal disorder and are frequently seen in primary care clinics, emergency wards, gastroenterology units, and surgical clinics.1–4 More than half of all people will at some point develop symptomatic hemorrhoids. However, half of those seeking care for hemorrhoids may in fact have another disorder, such as fissure, anal abrasion or irritation, or a skin tag.