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Background

Hemorrhoids are swollen blood vessels in the lower rectum. They are among the most common causes of anal pathology, and subsequently are blamed for virtually any anorectal complaint by patients and medical professionals alike. Confusion often arises because the term "hemorrhoid" has been used to refer to both normal anatomic structures and pathologic structures. In the context of this article, "hemorrhoids" refers to the pathologic presentation of hemorrhoidal venous cushions. Hemorrhoidal venous cushions are normal structures of the anorectum and are universally present unless a previous intervention has taken place. Because of their rich vascular supply, highly sensitive location, and tendency to engorge and prolapse, hemorrhoidal venous cushions are common causes of anal pathology.[1] Symptoms can range from mildly bothersome, such as pruritus, to quite concerning, such as rectal bleeding. Although hemorrhoids are a common condition diagnosed in clinical practice, many patients are too embarrassed to ever seek treatment. Consequently, the true prevalence of pathologic hemorrhoids is not known.[2] In addition, although hemorrhoids are responsible for a large portion of anorectal complaints, it is important to rule out more serious conditions, such as other causes of gastrointestinal (GI) bleeding, before reflexively attributing symptoms to hemorrhoids.[3] In a study of 198 physicians from different specialties, Grucela et al found the rate of correct identification for 7 common, benign anal pathologic conditions (including anal abscess, fissure, and fistula; prolapsed internal hemorrhoid; thrombosed external hemorrhoid; condyloma acuminata; and full-thickness rectal prolapse) was greatest for condylomata and rectal prolapse and was lowest for hemorrhoidal conditions.[4] There was no correlation between diagnostic accuracy and years of physician experience. The investigators found the overall diagnostic accuracy among the physicians to be 53.5%, with the accuracy for surgeons being 70.4% and that for the rest of the doctors being less than 50%.[4]

Historical note
Hemorrhoidal symptoms have historically been treated with dietary modifications, incantations, voodoo, quackery, and application of a hot poker. Molten lead has also been described as a treatment. The adverse effects of these treatments have a direct relationship to whether patients relay persistent or recurrent complaints to the clinician or return for further treatment. For patient education information, see Hemorrhoids, Anal Abscess, Rectal Pain, and Rectal Bleeding. See also the following:

Anal Surgery for Hemorrhoids Thrombosed External Hemorrhoid Excision

Anatomy
Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg, arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz muscle), and connective tissue lined by the normal epithelium of the anal canal. Hemorrhoids are present in utero and persist through normal adult life. Evidence indicates that hemorrhoidal bleeding is arterial and not venous. This evidence is supported by the bright red color and arterial pH of the blood. Hemorrhoids are classified by their anatomic origin within the anal canal and by their position relative to the dentate line; thus, they are categorized into internal and external hemorrhoids (see the following image).

Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc. External hemorrhoids develop from ectoderm and are covered by squamous epithelium, whereas internal hemorrhoids are derived from embryonic endoderm and lined with the columnar epithelium of anal mucosa. Similarly, external hemorrhoids are innervated by cutaneous nerves that supply the perianal area. These nerves include the pudendal nerve and the sacral plexus. Internal hemorrhoids are not supplied by somatic sensory nerves and therefore cannot cause pain. At the level of the dentate line, internal hemorrhoids are anchored to the underlying muscle by the mucosal suspensory ligament. Hemorrhoidal venous cushions are a normal part of the human anorectum and arise from subepithelial connective tissue within the anal canal. Internal hemorrhoids have 3 main cushions, which are situated in the left lateral, right posterior (most common), and right anterior areas of the anal canal. However, this combination is found in only 19% of patients; hemorrhoids can be found at any position within the rectum. Minor tufts can be found between the major cushions. Present in utero, these cushions surround and support distal anastomoses between the superior rectal arteries and the superior, middle, and inferior rectal veins. They also contain a subepithelial smooth muscle layer, contributing to the bulk of the cushions. Normal hemorrhoidal tissue accounts for approximately 15-20% of resting anal pressure and provides important sensory information, enabling the differentiation between solid, liquid, and gas. External hemorrhoidal veins are found circumferentially under the anoderm; they can cause trouble anywhere around the circumference of the anus.

Venous drainage of hemorrhoidal tissue mirrors embryologic origin. Internal hemorrhoids drain through the superior rectal vein into the portal system. External hemorrhoids drain through the inferior rectal vein into the inferior vena cava. Rich anastomoses exist between these 2 and the middle rectal vein, connecting the portal and systemic circulations. Mixed hemorrhoids are confluent internal and external hemorrhoids.

Etiology and Pathophysiology


The term hemorrhoid is usually related to the symptoms caused by hemorrhoids. Hemorrhoids are present in healthy individuals. In fact, hemorrhoidal columns exist in utero. When these vascular cushions produce symptoms, they are referred to as hemorrhoids. Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed. Most symptoms arise from enlarged internal hemorrhoids. Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal. The engorged anal mucosa is easily traumatized, leading to rectal bleeding that is typically bright red due to high blood oxygen content within the arteriovenous anastomoses. Prolapse leads to soiling and mucus discharge (triggering pruritus) and predisposes to incarceration and strangulation. Although many patients and clinicians believe that hemorrhoids are caused by chronic constipation, prolonged sitting, and vigorous straining, little evidence to support a causative link exists. Some of these potential etiologies are briefly discussed below.

Decreased venous return


Most authors agree that low-fiber diets cause small-caliber stools, which result in straining during defecation. This increased pressure causes engorgement of the hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause hemorrhoidal problems, presumably by means of the same mechanism, which is thought to be decreased venous return. Prolonged sitting on a toilet (eg, while reading) is believed to cause a relative venous return problem in the perianal area (a tourniquet effect), resulting in enlarged hemorrhoids. Aging causes weakening of the support structures, which facilitates prolapse. Weakening of support structures can occur as early as the third decade of life.

Straining and constipation


Straining and constipation have long been thought of as culprits in the formation of hemorrhoids. This may or may not be true.[5, 6, 7] Patients who report hemorrhoids have a canal resting tone that is higher than normal. Of interest, the resting tone is lower after hemorrhoidectomy than it is before the procedure. This change in resting tone is the mechanism of action of Lord dilatation, a surgical procedure for anorectal complaints that is most commonly performed in the United Kingdom.

Pregnancy
Pregnancy clearly predisposes women to symptoms from hemorrhoids, although the etiology is unknown. Notably, most patients revert to their previously asymptomatic state after delivery. The relationship between pregnancy and hemorrhoids lends credence to hormonal changes or direct pressure as the culprit.

Portal hypertension and anorectal varices


Portal hypertension has often been mentioned in conjunction with hemorrhoids.[8, 9, 10] However, hemorrhoidal symptoms do not occur more frequently in patients with portal hypertension than in those without it, and massive bleeding from hemorrhoids in these patients is unusual. Bleeding is very often complicated by coagulopathy. If bleeding is found, direct suture ligation of the offending column is suggested. Anorectal varices are common in patients with portal hypertension.[11] Varices occur in the midrectum, at connections between the portal system and the middle and inferior rectal veins. Varices occur more frequently in patients who are noncirrhotic, and they rarely bleed. Treatment is usually directed at the underlying portal hypertension. Emergent control of bleeding can be obtained with suture ligation. Portosystemic shunts and transjugular intrahepatic portosystemic shunts (TIPS) have been used to control hypertension and thus, the bleeding.[12]

Other risk factors


Other risk factors historically associated with the development of hemorrhoids include the following:

Lack of erect posture Familial tendency Higher socioeconomic status Chronic diarrhea Colon malignancy Hepatic disease Obesity Elevated anal resting pressure Spinal cord injury Loss of rectal muscle tone Rectal surgery

Episiotomy Anal intercourse Inflammatory bowel disease, including ulcerative colitis, and Crohn disease

Pathophysiology of symptoms of internal hemorrhoids


Internal hemorrhoids cannot cause cutaneous pain, because they are above the dentate line and are not innervated by cutaneous nerves. However, they can bleed, prolapse, and, as a result of the deposition of an irritant onto the sensitive perianal skin, cause perianal itching and irritation. Internal hemorrhoids can produce perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain. This constellation of symptoms is referred to as acute hemorrhoidal crisis and usually requires emergent treatment. Internal hemorrhoids most commonly cause painless bleeding with bowel movements. The covering epithelium is damaged by the hard bowel movement, and the underlying veins bleed. With spasm of the sphincter complex elevating pressure, the internal hemorrhoidal veins can spurt. Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This mucus with microscopic stool contents can cause a localized dermatitis, which is called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders.

Pathophysiology of symptoms of external hemorrhoids


External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually related to a specific event, such as physical exertion, straining with constipation, a bout of diarrhea, or a change in diet. These are acute, painful events. Pain results from rapid distention of innervated skin by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolution of the thrombosis. With this resolution, the stretched anoderm persists as excess skin or skin tags. External thromboses occasionally erode the overlying skin and cause bleeding. Recurrence occurs approximately 40-50% of the time, at the same site (because the underlying damaged vein remains there). Simply removing the blood clot and leaving the weakened vein in place, rather than excising the offending vein with the clot, will predispose the patient to recurrence.

External hemorrhoids can also cause hygiene difficulties, with the excess, redundant skin left after an acute thrombosis (skin tags) being accountable for these problems. External hemorrhoidal veins found under the perianal skin obviously cannot cause hygiene problems; however, excess skin in the perianal area can mechanically interfere with cleansing.

Epidemiology
Worldwide, the prevalence of symptomatic hemorrhoids is estimated at 4.4% in the general population. In the United States, up to one third of the 10 million people with hemorrhoids seek medical treatment, resulting in 1.5 million related prescriptions per year. The number of hemorrhoidectomies performed in US hospitals is declining. A peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate declined to 37 hemorrhoidectomies per 100,000 people in 1987. Outpatient and office treatment of hemorrhoids account for some of this decline. Patients presenting with hemorrhoidal disease are more frequently white, from higher socioeconomic status, and from rural areas. There is no known sex predilection, although men are more likely to seek treatment. However, pregnancy causes physiologic changes that predispose women to developing symptomatic hemorrhoids. As the gravid uterus expands, it compresses the inferior vena cava, causing decreased venous return and distal engorgement. External hemorrhoids occur more commonly in young and middle-aged adults than in older adults. The prevalence of hemorrhoids increases with age, with a peak in persons aged 45-65 years.

Prognosis
Most hemorrhoids resolve spontaneously or with conservative medical therapy alone. However, complications can include thrombosis, secondary infection, ulceration, abscess, and incontinence. The recurrence rate with nonsurgical techniques is 10-50% over a 5-year period, whereas that of surgical hemorrhoidectomy is less than 5%. Regarding complications from surgery, well-trained surgeons should experience complications in fewer than 5% of cases. Complications include stenosis, bleeding, infection, recurrence, nonhealing wounds, and fistula formation. Urinary retention is directly related to the anesthetic technique used and to the perioperative fluids administered. Limiting fluids and the routine use of local anesthesia can reduce urinary retention to less than 5%.

History
Most laypersons and many practitioners attribute all perianal symptoms to hemorrhoids. The astute clinician can often listen to a patient's description of symptoms and ascertain the source of the problem or condition before confirmatory examination. Nonhemorrhoidal causes of

symptoms (eg, fissure, abscess, fistula, pruritus ani, condylomata, and viral or bacterial skin infection) need to be excluded. The most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse. Because these symptoms are extremely nonspecific and may be seen in a number of anorectal diseases, the physician must therefore rely on a thorough history to help narrow the differential diagnosis and must perform an adequate physical examination (including anoscopy when indicated) to confirm the diagnosis. Familial predisposition, diet, a history of constipation or diarrhea, and a history of prolonged sitting or heavy lifting are also relevant, as are weight loss, abdominal pain, or any change in appetite or bowel habits. The presence of pruritus or any discharge should also be noted. Inflammatory bowel diseases (eg, ulcerative colitis, Crohn disease) need to be ruled out as the cause of symptoms. Human immunodeficiency virus (HIV) infection and other immunosuppressive diseases can also alter treatment plans.

Symptoms
An adequate history should include the onset and duration of symptoms. In addition to characterizing any pain, bleeding, protrusion, or change in bowel habits, special attention should be placed on the patient's coagulation history and immune status. Rectal bleeding is the most common presenting symptom. The blood is usually bright red and may drip, squirt into the toilet bowl, or appear as streaks on the toilet paper. The physician should inquire about the quantity, color, and timing of any rectal bleeding. Darker blood or blood mixed with stool should raise suspicion of a more proximal cause of bleeding. A patient with a thrombosed external hemorrhoid may present with complaints of an acutely painful mass at the rectum (see the image below). Pain truly caused by hemorrhoids usually arises only with acute thrombus formation. This pain peaks at 48-72 hours and begins to decline by the fourth day as the thrombus organizes. New-onset anal pain in the absence of a thrombosed hemorrhoid should prompt investigation for an alternate cause, such as an intersphincteric abscess or anal fissure. As many as 20% of patients with hemorrhoids will have concomitant anal fissures.

Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of clot.

The presence, timing, and reducibility of prolapse, when present, will help classify the grade of internal hemorrhoids and guide the therapeutic approach (see Grading of Internal Hemorrhoids). Grade I internal hemorrhoids are usually asymptomatic but, at times, may cause minimal bleeding. Grades II, III, or IV internal hemorrhoids usually present with painless bleeding but also may present with complaints of a dull aching pain, pruritus, or other symptoms due to prolapse.

Physical Examination
In addition to the general physical examination, physicians should also perform visual inspection of the rectum, digital rectal examination, and anoscopy or proctosigmoidoscopy when appropriate. The preferred position for the digital rectal examination is the left lateral decubitus with the patient's knees flexed toward the chest. Topical anesthetics (eg, 20% benzocaine or 5% lidocaine ointment) may help to reduce any discomfort caused by examination. Inspect and examine the entire perianal area. Warn the patient before any probing or poking. Because patient apprehension is great before any anal examination, go to great lengths to reassure the patient. Gentle spreading of the buttocks allows easy visualization of most of the anoderm; this includes the distal anal canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without internal probing. Note the location and size of skin tags and the presence of thromboses. Normal corrugation of the anoderm and a normal anal wink with stimulation confirms intact sensation. The following are external findings that are important to note:

Redundant tissue Skin tags from old thrombosed external hemorrhoids Fissures Fistulas Signs of infection or abscess formation Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass

Digital examination of the anal canal can identify any indurated or ulcerated areas. Also assess for any masses, tenderness, mucoid discharge or blood, and rectal tone. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft vascular structures, they are usually not palpable unless thrombosed. Current guidelines from most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids such as in

the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

Grading of Internal Hemorrhoids


Most clinicians use the grading system proposed by Banov et al in 1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches, as follows.

Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases (ie, return to their resting point by themselves) Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction (ie, require manual effort for replacement into the anal canal) Grade IV hemorrhoids chronically prolapse and cannot be reduced; these lesions usually contain both internal and external components and may present with acute thrombosis or strangulation

Diagnostic Considerations
Hemorrhoidal complaints are usually not associated with other medical conditions or diseases. However, patients with the following diseases and conditions have an increased risk of hemorrhoidal complaints:

Inflammatory bowel disease (IBD): IBD and hemorrhoidal problems occur frequently; unusual hemorrhoidal presentations and findings should alert the clinician to the potential of IBD. Ulcerative colitis and Crohn disease Pregnancy

Varicosities caused from portal hypertension are a distinct entity from hemorrhoids. Other conditions that should be considered when evaluating a patient with suspected hemorrhoids include anal cancer, anal fissures, and anal fistulae; pedunculated polyps; perianal abscesses; pruritus ani; and colorectal tumors.

Differential Diagnoses

Condyloma Acuminata Proctitis Rectal Prolapse

Approach Considerations
Most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

Hematologic Tests
A complete blood cell (CBC) count may be useful as a marker for infection. Anemia due to hemorrhoidal bleeding is possible,[3] albeit rare (0.5 cases per 100,000 patients), and its presence should raise suspicion of an alternate diagnosis. Hematocrit testing is suggested if excessive bleeding with concomitant anemia is suspected. Coagulation studies are indicated if the history and physical examination suggest coagulopathy.

Anoscopy and Flexible Sigmoidoscopy


Anoscopy is mandatory for viewing internal hemorrhoids. The anoscope should be a side-viewing one. When angled well by the examiner, the side-viewing anoscope allows the soft hemorrhoidal tufts to fill the beveled end of the scope and to be appropriately evaluated. Prolapse can be observed when the patient performs a Valsalva maneuver. Flexible sigmoidoscopy is performed to exclude proximal disease. Having a patient strain while sitting on a toilet may reproduce prolapse most accurately; in addition, examining patients while they sit on a toilet can be very helpful in indeterminate cases.

Other Diagnostic Imaging Studies


Proctoscopy may be performed to supplement anoscopy, and proctography may be indicated in rectal prolapse. Colonoscopy, virtual colonoscopy, and barium enema are reserved for cases of bleeding without an identified anal source. These symptoms are not attributable to hemorrhoids and are considered to be nonoutlet-type bleeding. Barium enema study or virtual colonoscopy is also suggested if proximal colonic and intestinal diseases must be excluded and if endoscopy is not helpful. Full evaluation of the large bowel with colonoscopy is recommended for patients with significant abdominal symptoms, weight loss, change in bowel habits, age older than 50 years, or other risk factors for colonic malignancy.

Histologic Features

Routine histologic examination of hemorrhoidal tissue is usually unrewarding, especially if it is grossly examined by an experienced anorectal surgeon. Any suspicious tissue must be sent for microscopic evaluation. External hemorrhoids are classified by the underlying pathology and symptoms, which include thrombosed veins, bleeding from eroded blood clots, and skin tags causing hygiene problems.

Approach Considerations
Treat hemorrhoids only when the patient complains of them. The old adage that it is hard to make an asymptomatic patient better applies here. No matter how bad the hemorrhoids look to the practitioner, they should not be treated unless they bother the patient. Treatment of hemorrhoids is divided by the cause of symptoms, into internal and external treatments. Accurately classifying a patient's symptoms and the relation of the symptoms to internal and external hemorrhoids is important.

Internal hemorrhoids
Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic, and the treatment may be surgical or nonsurgical. Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms that persist despite the use of conservative therapy. Most nonsurgical procedures currently available are performed in the clinic or ambulatory setting. The following is a quick summary of treatment for internal hemorrhoids by grade:

Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods Grade II or III hemorrhoids are initially treated with nonsurgical procedures Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation

Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), is an excellent alternative for treating internal hemorrhoids that have not been amenable to conservative or nonoperative approaches. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with procedure for prolapsing hemorrhoids and skin tag excision. Operative resection is sometimes required to control the symptoms of internal hemorrhoids.

External hemorrhoids

External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), whereas operative resection is reserved for the latter. Remember that therapy is directed solely at the symptoms, not at aesthetics. When performed well, operative hemorrhoidectomy should have a 2-5% recurrence rate. Nonoperative techniques, such as rubber band ligation, produce recurrence rates of 30-50% within 5-10 years. However, these recurrences can usually be addressed with further nonoperative treatments.[13] Long-term results from procedure for prolapsing hemorrhoids are unavailable at this time.[14, 15, 16]

Controversies
The major controversies regarding the treatment of hemorrhoids center on the indications for treatment and the choice of operative versus nonoperative therapy. Most experienced surgeons are using office-based nonoperative therapies and are relying less on operative hemorrhoidectomy than they previously were. In the United States, rubber band ligation (compared with injection sclerotherapy) is the mainstay of conservative treatment. Procedure for prolapsing hemorrhoids (PPH), which has been gaining increasing favor in the United States, provides an excellent alternative to operative hemorrhoidectomy for patients with minimal external disease and large internal hemorrhoids.

Emergency Department Care


Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset. (See Thrombosed External Hemorrhoid Excision) Infiltration of a local anesthetic containing epinephrine is followed by elliptical incision and excision of the thrombosed hemorrhoid, its accompanying vein, and overlying skin. Simple incision and clot evacuation is inadequate therapy and should not be performed. Simple incision and clot evacuation is inadequate therapy and should not be performed. The incision should not extend beyond the anal verge or deeper than the cutaneous layer. A pressure dressing is applied for several hours, after which time the wound is left to heal by secondary intention. In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable. (See Conservative Management.)

Conservative Management
Medical management is the initial treatment of choice for grade I internal and nonthrombosed external hemorrhoids. It consists of warm baths (twice or thrice daily [bid/tid]); a high-fiber

diet[17] ; adequate fluid intake; stool softeners; topical and systemic analgesics; proper anal hygiene; and in some cases, a short course of topical steroid cream. A 2012 review indicates a potential benefit of phlebotonics in treating hemorrhoids.[18] Retraining the patient's toilet habit is also a consideration. Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, first-line treatment of all first- and second-degree (and many third- and fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation. Many patients see improvement or complete resolution of their symptoms with conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after 1 month of conservative therapy. Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids.

Warm baths
Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. Some authors do not suggest mechanisms such as the sitz bath for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role in the treatment of older or immobile patients who cannot routinely get in and out of a bathtub.

High-fiber diet
Psyllium seed significantly decreases bleeding and pain compared with placebo. Psyllium seed (Metamucil) and methylcellulose (Citrucel) are the most commonly used supplements. The average American diet consists of 8-15 g of fiber per day; a high-fiber diet includes more than 25 g of fiber per day. Many hemorrhoidal symptoms resolve only when they are treated with dietary alterations, including increased fiber and the addition of fiber supplements.

Antidiarrheal agents, toilet habit retraining, and stool softeners


Antidiarrheal agents are sometimes required in patients with hemorrhoidal symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids. Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, also have a small role in the treatment of hemorrhoidal symptoms.

Topical agents
The use of topical steroids has not been well-studied in the treatment of thrombosed hemorrhoids; however, these agents can be used to decrease symptoms of pruritus and inflammation. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. It is important to consider the principles of steroid use and the associated side effects, such as mucosal atrophy. As such, the prolonged use of topical steroids should be avoided. Some authors rarely recommend typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. Submucosal veins do not get smaller with anti-inflammatory medications. Topical nitroglycerine and nifedipine have also been used to relieve symptoms associated with anal sphincter spasm.[19, 20] These agents should also be used with caution because of associated side effects, such as hypotension. Good evidence suggests that high-fiber diets in particular help reduce severity and duration of symptoms.

Nonsurgical Procedures
Numerous nonoperative methods to destroy internal hemorrhoids are available. Nonsurgical techniques function by rubber band ligation, ablation, sclerosis, or necrosis of mucosal tissues.[21, 22, 23] Despite several meta-analyses and considerable personal preference, there is no clear advantage of one technique over the others; however, all should be the first-line treatment of all first- and second-degree internal hemorrhoids that do not respond to conservative therapy. All nonoperative treatments have approximately similar efficacy when administered by an experienced clinician. Lord dilatation, in which the anal canal is manually stretched under anesthesia, is seldom used in the United States, and many colorectal surgeons condemn its use, because it is essentially an uncontrolled disruption of the sphincter mechanism.

Contraindications for nonsurgical techniques


The following conditions are contraindications for performing the nonsurgical procedures mentioned above:

Acquired immunodeficiency syndrome (AIDS): Human immunodeficiency virus (HIV) infection and anal disease often occur togetherconservative therapy is suggested, especially if immunosuppression is evident; poor healing occurs with low CD4 counts, especially when less than 200 cells/mm3 Immunodeficiency disorders Coagulopathy Irritable bowel disease

Pregnancy: This condition is associated with many anorectal complaints; nonoperative treatment or office thrombectomy usually relieves complaints, although operative hemorrhoidectomy is safe in pregnant women[24] Immediate postpartum period Rectal wall prolapse Large anorectal fissure or infection Tumor

Rubber band ligation


Rubber band ligation is the most-used remedy for grade II and grade III hemorrhoids and is the standard by which other methods are compared. This procedure is most common in the United States, because it is the most commonly taught method in training programs.[13] With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively. Blaisdell[25] and Barron[26] described and refined ligation therapy. A band ligature is passed through an anoscope and placed on the rectal mucosa proximal to the dentate line. The tissue necroses and sloughs off in 1-2 weeks, leaving an ulcer that later fibroses. No anesthesia is required; complications are uncommon and usually benign. When Jutabha et al compared endoscopic rubber band ligation with bipolar electrocoagulation for chronically bleeding grade II or III internal hemorrhoids that were unresponsive to medical therapy, ligation controlled rectal bleeding and other symptoms with significantly fewer treatments (2.3 0.2) and had a significantly higher success rate (92%) than electrocoagulation (3.8 0.4 and 62%, respectively).[27] However, severe pain during treatment occurred more often with ligation (8%) than with electrocoagulation (0%), albeit treatment failure and crossovers were significantly less frequent (8% vs 38%). Necrotizing pelvic sepsis is a rare, but serious, complication of rubber band ligation. The diagnosis is suggested by the triad of severe pain, fever, and urinary retention. It occurs 1-2 weeks after ligation, frequently in immune-compromised patients, and requires prompt surgical debridement.

Coagulation, electrocautery, and electrotherapy


Infrared coagulation serves best for grades I and II and some grade III hemorrhoids. This method may be as effective as banding with fewer and less severe complications. Bipolar electrocautery is best for lower-grade hemorrhoids; this technique quickly coagulates the hemorrhoid tissue but has no effect on prolapse. Low-voltage direct current works best for higher-grade hemorrhoids. Low-voltage direct current requires grounding time and provides excellent control of pain.

Sclerotherapy and cryotherapy


Sclerotherapy can provide adequate treatment of early internal hemorrhoids.[28, 29] However, sclerotherapy and cryotherapy are infrequently used and generally reserved for grade I or II hemorrhoids. Although minimally invasive, these treatment methods have a higher rate of postprocedure pain. Impotence, urinary retention, and abscess formation have also been reported. Recurrence rates are as high as 30%.

Laser therapy and radiowave ablation


Laser therapy is more costly and provides no advantage over other methods. Operators must control the laser to avoid bleeding. Radiowave ablation followed by suture ligation could prove to be a safe, cost-effective, and convenient way to treat prolapsing hemorrhoids.[30]

Surgical Intervention
Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome. Treatment guidelines are available from the American Gastroenterological Association (AGA)[31] and the American Society of Colon and Rectal Surgeons (ASCRS).[32] Patients with ulcerative colitis can tolerate aggressive surgery if it is needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women.[24] Hemorrhoid surgery can usually be performed using local anesthesia with intravenous (IV) sedation. Regional or general anesthetic techniques also are used. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas.

Excision of thromboses
External hemorrhoids generally elicit symptoms due to acute thromboses, recurrent thromboses, or hygiene problems. Manage acute thromboses and recurrent thromboses in a similar fashion. Identify the offending vascular cluster. In the office or clinical setting, inject local anesthetic, and then perform excision of the overlying skin and underlying veins.

Enucleation of the thrombosis alone can result in recurrence of the hemorrhoid at the same spot; excision of the underlying vein completely prevents this event. Electrocoagulation or topical astringent (Monsel solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone.

Surgical hemorrhoidectomy
Surgical hemorrhoidectomy is the most effective treatment for all hemorrhoids and in particular is indicated in the following situations:

Conservative or nonsurgical treatment fails (persistent bleeding or chronic symptoms) Grade III and IV hemorrhoids with severe symptoms Presence of concomitant anorectal conditions (eg, anal fissure or fistula, hygiene trouble caused by large skin tags, a history of multiple external thromboses, or internal hemorrhoid trouble) requiring surgery Patient preference

About 5-10% of people with hemorrhoids eventually require surgical hemorrhoidectomy. Proper anesthetic care (especially if local anesthesia with supplementary IV sedation), attention to perioperative fluid restriction, and careful postoperative instructions can ease the patient's recovery. Postoperative pain remains the major complication, with most patients requiring 2-4 weeks before returning to normal activities. Other possible complications include urinary retention, anal stenosis, and incontinence. Nonlaser versus laser hemorrhoidectomy Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, one prospective study found no difference between scalpel and laser hemorrhoidectomy.[33] The reader is referred to appropriate textbooks to see descriptions of techniques used.[34, 35]

Stapled hemorrhoid surgery/ procedure for prolapsing hemorrhoids (PPH)


Stapled hemorrhoid surgery, or PPH, was first described in 1997-1998 and has become prominent.[36, 37, 14] This procedure is mainly used to treat internal hemorrhoids that are not amenable to conservative and nonoperative therapies. PPH is suggested for patients with large internal hemorrhoids and minimal external component. This procedure can be done in an outpatient setting with local anesthesia,[38, 39, 40, 41] similar to the protocol used for conventional

hemorrhoid surgery. Narcotic use and recovery is significantly decreased compared with conventional operative hemorrhoid surgery. During this procedure, a specially designed circular stapler with smaller staples is used. The technique involves placing a suture in the mucosal and submucosal layers circumferentially, approximately 3-4 cm above the dentate line. The stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a circular staple line above the dentate line, resulting in resection of excessive internal hemorrhoidal tissue, pexy of the internal hemorrhoidal tissue left behind, and interruption of the blood supply from above. PPH does not directly affect the external tissue. Reports have described shrinking of external hemorrhoidal tissue after PPH, probably from decreased blood flow. Good results from PPH combined with judicial excision of occasional skin tags also have been reported. Acute hemorrhoidal crisis Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is a large internal hemorrhoid prolapse. The sphincter mechanism squeezes, incarcerating the internal hemorrhoids and strangulating them. The resulting spasm causes edema and occasionally thrombosis of the external hemorrhoids. The resulting pain and swelling are dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported.

Long-Term Monitoring
After excision of a thrombosed external hemorrhoid, the patient may be discharged home for several hours of bedrest followed by warm baths 2-3 times daily, stool softeners, and topical or systemic analgesia. The patient should return in 48-72 hours for a wound check. All other patients should be referred to a surgical or rectal clinic for more definitive treatment and sent home with conservative medical therapy. Monitor patients at regular intervals until they are healed and have no symptoms. Attention to regular and soft bowel movements is important. Bulk agents (eg, psyllium seed) and oral fluids are important. Bathing in tubs for comfort and hygiene is part of the routine. Judicious narcotic administration relieves pain.[42] Patients should also be advised of the following:

Avoid constipation Weight loss Avoid prolonged sitting on the toilet Avoid prolonged sitting at work

Improved anorectal hygiene

Proceed to Medication

Medication Summary
The goals of pharmacotherapy are to reduce pain and constipation in patients with hemorrhoids.

Stool softeners
Class Summary
Stool-softening agents are used to avoid straining and constipation. View full drug information

Docusate sodium (Colace, Correctol, Dok, Dulcolax)

Docusate is indicated for patients who should avoid straining during defecation. This agent allows incorporation of water and fat into stool, causing stool to soften.

Topical anesthetics
Class Summary
Topical anesthetic agents are indicated for pain. View full drug information

Lidocaine ointment 5% (Lidoderm, Regenecare, LidaMantle)

Topical lidocaine increases permeability to sodium ions in neuronal membranes, resulting in inhibition of depolarization, blocking transmission of nerve impulses.

Mild astringent
Class Summary
This agent is used to relieve itching.

View full drug information

Hamamelis water (Witch Hazel)

Hamamelis water is a mild astringent prepared from twigs of Hamamelis virginiana. This agent is used to temporarily relieve the itching of hemorrhoids.

Analgesics
Class Summary
Pain control is essential to quality patient care. Analgesics ensure patient comfort, which is beneficial for patients who have painful lesions. View full drug information

Acetaminophen (Tylenol, Aspirin Free Anacin, Feverall, Mapap)

Acetaminophen is the drug of choice (DOC) for treatment of pain in patients with documented hypersensitivity to aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), with upper gastrointestinal (GI) disease, or who are taking oral anticoagulants. This agent reduces fever by direct action on the hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating.