REVIEWS

Conservative and surgical treatment

of haemorrhoids
Donato F. Altomare and Simona Giuratrabocchetta
Abstract | The management of haemorrhoids has evolved rapidly during the past few decades. Several
new treatments have been proposed with the aim of reducing patients’ postoperative pain, time to return
to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment
based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and
phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced
stages. Milligan–Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV
haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or
without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management
of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms
involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these
minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid
return to normal life without pain are greatly appreciated by patients. An algorithm for the management
of haemorrhoids using evidence‑based medicine is also presented here.
Altomare, D. F. & Giuratrabocchetta, S. Nat. Rev. Gastroenterol. Hepatol. 10, 513–521 (2013); published online 11 June 2013;
doi:10.1038/nrgastro.2013.91

Introduction
Haemorrhoid disease is the most frequent procto-
logic complaint, affecting a considerable proportion of
adults of any age (haemorrhoids very rarely occur in
children) and sex. This disease has been well described
since ancient times (Hammurabi Codex ~1750 B.C. in
Babilonia, Ebers Papyrus 1550 B.C. in Egypt). Treatment,
however, has only substantially evolved in the past few
decades, when decreasing postoperative pain and mini-
mizing the risk of postoperative bleeding and recurrence
became pivotal issues.
The true prevalence of haemorrhoids in the general
population is unknown and probably differs from country
to country.1 In a study by Riss et al.2 in 2012, the preva-
lence of haemorrhoids in adults undergoing colonoscopy
within the Austrian national screening programme for
colorectal cancer was 39%, although in most of the cases
they were classified as grade I haemorrhoids (Box 1). In
this Review, we describe the current treatment options for
the effective management of patients with haemorrhoid
disease. We also present a new treatment algorithm for
patients with grade I–IV haemorrhoids (Figure 1).
Aetiology
The aetiology of haemorrhoids is still debated and has
been at the centre of a medical argument during past
centuries. The Italian anatomist Morgagni (1682–1771)3
was a strong advocate for the varicose vein theory, which
Competing interests
The authors declare no competing interests.
states that humans are affected by haemorrhoids as a
consequence of having achieved the standing position.
The vascular theory, strongly supported by the discov-
ery of vascular connections between the portal venous
system and haemorrhoidal veins by John Hunter 4 and
later by Verneuil, 5 strongly influenced the medical
community until the end of the 20th century. The 19th
century theory of vascular hyperplasia was promoted by
Malgaigne (1837)6 and Shezner (1963)7 who interpreted
that haemor­rhoid cushions were corpus cavernosum­
recti and contributed to the maintenance of anal con-
tinence; this theory has never been substantiated
by histology.
Nowadays, the most accredited theory is that of the
sliding or displacement of anal lining mucosa of the anal
cushions originally proposed by Gass and Adams8 and
later popularized by Thomson in his doctoral thesis.9
This hypothesis is supported by emerging data showing
that haemorrhoids develop in individuals with a con-
genital or acquired collagen fragmentation of the
extracel­lular matrix and ligament of Treitz.10,11 Moreover,
Department of
mucosal prolapse usually precedes haemorrhoidal bleed- Emergency and Organ
ing, again providing support for the sliding theory. 9 Transplantation,
Policlinico Universitario
However, the venous theory is still supported by a group Bari, Piazza G. Cesare,
of researchers12 who found marked changes in arteriolar 11–70124 Bari, Italy
(D. F. Altomare,
and small venous size and morphology in patients with
S. Giuratrabocchetta).
haemorrhoids compared with healthy individuals. In
their view, repeated straining at defecation of hard stool Correspondence to:
D. F. Altomare
favours distal sliding of the anorectal mucosa outside the donatofrancesco.
anal ring. The high-pressure zone of the anal sphincter altomare@uniba.it

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REVIEWS
Key points
■■ Haemorrhoid treatment must be tailored to the severity of disease and the
patient’s expectation
■■ Conservative (including dietary, hygienic and medical) treatment is effective
in managing patients during the early stages of haemorrhoids
■■ Several new minimally invasive surgical options, including stapled mucopexy
and Doppler-guided haemorrhoid artery ligation, are now being offered to
patients with grade III haemorrhoids
■■ Patients with grade IV haemorrhoids need to undergo a haemorrhoidectomy, the
outcome of which is improved by the use of radiofrequency vessel sealing devices
Box 1 | Grading haemorrhoids according to Sir J. Goligher18
■■ Grade I indicates haemorrhoid cushions engorged and hyperaemic; they might
bleed but do not prolapse downward from their normal site during defecation
■■ Grade II indicates haemorrhoid cushions with prolapse of the mucosa into the
anal canal during pushing at defecation, but they spontaneously return to their
normal position in the anal canal at the end of the defecation
■■ Grade III haemorrhoids protrude from the anal canal during defecation or
spontaneously and “remain prolapsed afterwards until they are digitally replaced
within the anus”. The haemorrhoids look swollen, engorged, and often confluent
and, most importantly, do not return spontaneously into the anal canal
■■ Grade IV are long-lasting piles completely exteriorized with permanent
exteriorization of the anal mucosa and with a fibrotic skin, which prevents their
reposition within the anal canal
then promotes an increase in blood capillary pressure by
preventing an easy return of the venous blood, leading
to capillary vein engorgement and bleeding.
Risk factors
The important role of inadequate dietary fibre intake, life-
style and body mass in the development of haemor­rhoids
is supported by several ep­idemiological studies;13,14 the
relationship of haemorrhoids with chronic constipation,
however, was not confirmed in a later study by the same
authors.15 The popular opinion about the role of spicy
foods in the onset and deterior­ation of haemorrhoids has
been questioned by data from a prospective randomized
double-blinded placebo control trial,16 which failed to
demonstrate any adverse effect of red-hot chilli pepper
on 50 patients with haemorrhoids.
Haemorrhoids grading and exclusion of other rectal diseases
Grade I Grade II
Conservative medical Conservative medical
treatment treatment
EBM level II EBM level II
Recommendation B Recommendation B
Failure
Rubber band ligation
EBM level I
Recommendation A
Sclerotherapy
Infrared coagulation
Figure 1 | Evidence-based algorithm for the management of haemorrhoids. Evidence-based medicine (level I reflects data
from RCTs; level II concerns data from well-conducted, but small and underpowered RCTs) and grading of haemorrhoids
are developed from the recommendations according to Bellomo and Bagshaw.125 Abbreviations: DGHAL, Doppler-guided
haemorrhoid artery ligation; EBM, evidence-based medicine; PPH, stapled haemorrhoidectomy; RCT, randomized control trial.
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Classification
The treatment of haemorrhoids can be conservative in
the majority of cases, but surgery is often required in the
most advanced stages. Therefore, a disease classification
and grading is of great importance for therapeutic pur-
poses. Despite several limitations and attempts to improve
it,17 the classification system proposed by Sir Goligher 18
more than 50 years ago, which is essentially based on the
amount and reducibility of haemorrhoid prolapse, is still
the most commonly adopted system by proctologists
(Box 1). The main reason for its popularity is that it is easy
to remember and has practical implications. Nevertheless,
it should be noted that Goligher’s classification has some
limitations: the prolapse of a single haemorrhoid mucosa
is not mentioned, external piles are not taken into account
and the fact that acute haemorrhoid thrombosis can lead
to an overestimation of disease severity is not considered.
On the other hand, the amount of internal mucosal pro-
lapse evident with the patient laid in lithotomic position
under anaesthesia can be underestimated during a simple
proctologic visit to an outpatient clinic, leading to the
potential for the incorrect grading of the haemorrhoids.
Medical treatment
Patients with haemorrhoids of any degree of severity
should undertake some dietary and lifestyle modifi­cation,
which can sometimes be enough to manage the early
stages of disease. An old adage on haemorrhoid disease
claims that if you look after your bowel your haemorrhoids
will look after themselves. All medical and hygienic sug-
gestions for the control of haemorrhoid symptoms should
be considered, as an easy and regular defecation of soft
stool can help to prevent, or at least limit, anal mucosal
prolapse. The prescription of a high-fibre diet and ade-
quate water intake is, in fact, the first medical advice to
these patients and often the oral supplement of hydrophilic
bulk-forming colloids is of beneficial effect. However, the
literature on the role of dietary habit on haemorrhoids is
scarce and dated. Sielezneff 19 found that dietary imbal-
ance (increased fat, alcohol and pepper intake, but not
fibre intake) together with smoking, low water intake and
Grade III Grade IV
For low For low
pain recurrence
rate Milligan–Morgan
or Ferguson
haemorrhoidectomy
PPH/EEA stapled mucopexy
EBM level I
Recommendation A
or
Mucopexy ± DGHAL By radiofrequency device
EBM level I EBM level I
Recommendation A Recommendation A

Table 1 | Surgical treatment for grade III haemorrhoids
Procedure Description
Milligan–Morgan Removal of prolapsed haemorrhoids
haemorrhoidectomy
Ferguson Removal of prolapsed haemorrhoids
haemorrhoidectomy Suture of mucosa
Mucopexy Mucopexy of 5–6 haemorrhoid
arteries by running suture
Doppler-guided Doppler-guided ligation of 5–6
haemorrhoid artery ligation haemorrhoid arteries and mucopexy
with mucopexy by running suture
Stapled haemorrhoidopexy Stapler resection and/or anastomosis
of a ring of the prolapsing mucosa
above the dentate line
constipation were more frequently observed in patients
with haemorrhoids than in healthy volunteers.
A meta-analysis in 2005 including seven randomized
controlled trials (RCTs) and 378 patients with haemor-
rhoids found that oral fibre supplementation could halve
the relative risk of bleeding (RR 0.50, 95% CI 0.28–0.89).20
Sometimes prebiotics (such as inulin and fructose oligo-
saccharides) and probiotics are included as supplements
to improve defecation of soft and hydrated stools. In fact,
a prospective RCT suggested a role of ‘bran therapy’ to
improve the long-term result of conservative treatment of
grade III haemorrhoids.21 A meta-analysis also concluded
that fibre supplementation in patients with haemor­
rhoids was able to induce consistent beneficial effects on
bleeding, pain and itching.22 However, no additional evi-
dence has found that probiotics can have other effects on
haemor­rhoid symptoms. In conclusion, although the role
of fibre in the prevention of haemorrhoids is unclear, a
sufficient body of evidence exists to support its utility for
the control of their sy­mptoms through the promotion of
an easy defecation.
Another common medical prescription in patients with
bleeding haemorrhoids is phlebotonic drugs c­ omprising
flavonoids (plant extracts) and synthetic compounds.
These drugs include oxerutin, diosmin, hesperidin,
cumarin and quercetin, all of which act as pronounced
scavengers of hydroxyl radicals. Several prospec-
tive studies have explored the utility of these drugs for
haemor­rhoid symptoms and a meta-analysis23 of 14
e­ligible trials with 1,514 patients found that the use of
flavonoids decreased symptoms by 58% as well as the risk
of bleeding and recurrence rate. However, limitations in
the quality and heterogeneity of the trials examined make
this conclusion unreliable and their use in the USA has
not yet been approved by the FDA.
In conclusion, medical treatments can improve symp-
toms at any stage of haemorrhoid disease; nonresponders­,
however, should undergo further treatment.
Management of haemorrhoids
Grade I–II: conservative treatment
Conservative outpatient treatments, such as rubber
band ligation,24 infrared coagulation,25 radiofrequency
ablation26 and sclerotherapy,27 can be used to effectively
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Advantages Disadvantages
Low cost Intense and prolonged
Low recurrence postoperative anal pain
Low cost Intense and prolonged
Low recurrence postoperative anal pain
Fast wound healing
Low postoperative pain High recurrence rate
Fast recovery
Low postoperative pain High recurrence rate
Fast recovery Increased cost
Low postoperative pain High recurrence rate
Fast recovery Increased cost
Rare, but severe, complications
manage grade I and II haemorrhoids. The most popular
and effective treatment is rubber band ligation, which
has been shown to be superior to sclerotherapy 28 and
infrared coagulation.29 The rationale of the technique is
that ligation leads to ischaemia and necrosis of the pro-
lapsing mucosa followed by scar fixation to the rectal
muscular wall. This quick technique is well-tolerated
in patients as the ligature is performed well above the
dentate line where somatic sensitivity is absent. One
large case series30 including 750 consecutive patients with
grade II and III haemorrhoids reported a curative rate
of 93% and a recurrence rate of 11% after 2 years, with
7% of patients reporting minor complications. Rubber
band ligation can now be performed without assistance,
and usually in a single session, following the develop-
ment of several commercial instruments that use suction
and ligation techniques.31 Complications such as bleed-
ing and pain are rare; the recurrence rate, however, is
~40% in the long term,30 although the procedure can be
repeated safely.
Alternative conservative treatments, although avail-
able, are less commonly used. These approaches are
based on the induction of necrosis of the mucosa and
submucosa above the dentate line and to promote the
formation of scar tissue on the surface of the rectal wall
by either thermal (infrared coagulation) or chemical
(aluminum potassium sulphate and tannic acid, 50%
dextrose water) means.32,33 A further nonoperative treat-
ment, cryotherapy,34 was popular in the 1980s but is now
almost completely abandoned and discouraged by the
American Society of Colon and Rectal Surgery guidelines
because of unsatisfactory results.35
Grade III: surgical treatment
Surgical treatment of grade III haemorrhoids is the most
controversial issue in haemorrhoid treatment. This
controvers­y exists not only because this condition rep-
resents the vast majority of indications for surgery (>90%
of cases), but also because several surgical options have
been put forward, yet there is little consensus of which
option is best (Table 1).
Actually, the surgical approach used should be selected
on the basis of the type of outcome the patient or the
surgeon is looking for. Evaluating the outcome of surgery
REVIEWS
could be based on recurrence rate, symptoms recurrence,
postoperative pain or cost-effectiveness. Even the com-
plication rate and the functional outcome could be a
reasonable reason to choose one approach over another.
A classic example of this controversy is the choice of
stapled haemorrhoidopexy. If postoperative pain or time
to return to work is considered, this operation could be
the first option36 (evidence level I, conclusion supported
by RCT data), but if recurrence and cost of the procedure
is concerned, the Milligan–Morgan operation should be
preferred (evidence level I). Making a decision on which
approach is best is therefore difficult.
In the late 1990s, extensive effort was spent developing
new surgical approaches for treating haemorrhoids, as
alternatives to the classic Milligan–Morgan operation.
These approaches were based on a pathophysiological
approach and aimed to spare the sensitive anoderm and
reduce postoperative pain. In 1995, Morinaga et al.37
described the technique of Doppler-guided haemorrhoid
artery ligation (DGHAL), which was based on the vas-
cular theory of haemorrhoids and decreased blood flow
to haemorrhoid cushions. In 1998, Longo38 presented
his new technique (namely stapled haemorrhoidopexy),
which was developed from Thompson’s theory of the
sliding mucosa.
DGHAL
DGHAL was originally indicated for grade II haem-
orrhoids and it had encouraging short-term results
with low levels of postoperative morbidity at 30 days.39
A further development of this technique enabled the
addition of a mucopexy through a modified anoscope,
making it possible to both reduce the blood flow to the
anal cushions as well as their lifting and fixation in
the high anal canal. This new method, termed t­­ransanal
haemorrhoidal deartierialization, was successfully
applied to grade III haemorrhoids and reported good
results even in the medium term (1–5 years) and a
12–27% recurrence rate.40–41 A further modification of
this technique—the so-called haemorrhoidal laser proce-
dure (HeLP)—involves the use of lasers to close haemor-
rhoid arteries (identified by a Doppler probe) followed
by mucopexy.42
Three RCTs have compared DGHAL and mucopexy
with stapled haemorrhoidopexy. 43–45 Two of these
studies44,45 showed no statistically significant difference
between the approaches in terms of pain, postoperative
complications and recurrence rate, but a reduced equip-
ment cost and shorter hospital stay for DGHAL. One
study 43 reported markedly less postoperative pain and
operative time for DGHAL than stapled haemorrhoid­
o­p exy. A systematic review including 28 studies and
a total of 2,904 patients reported a pooled recurrence
rate of 17.5% (of note, some grade IV haemorrhoids were
also included), a postoperative bleeding rate of 5% and
a re‑intervention rate of 6.4%.46 This technique has now
been recognized by NICE.47
DGHAL was also compared with haemorrhoidectomy,
showing, unsurprisingly, markedly reduced post­operative
pain with no differences in the rate of long-term
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complications or recurrence.48 However, two RCTs from
the past 2 years that compared the outcome of mucopexy
plus DGHAL with mucopexy non-Doppler guided,
reported no differences in the rate of complications or
recurrence between the two approaches. However, a
reduced operative time and pain score was reported for
the simple mucopexy in one49 and greater improvement
of prolapse symptoms in the non-Dopple­r group in the
second.50 If these data are confirmed, the role of DGHAL
could have been overestimated. Indeed, Schuurman, 51
using anal colour Doppler endo­s onography both
before surgery and 6 months after, showed no statisti-
cally significant changes in vascular anatomy of the
anal canal between patients treated for haemorrhoids
using DGHAL and mucopexy (n = 34) compared with
non‑Doppler guided mucopexy (n = 30).
Stapled haemorrhoidopexy
Although the use of a circular stapler for haemorrhoids
was attempted by others,52 the idea of repositioning the
mucosal prolapse high into the anal canal by resecting
a mucosal ring well above the dentate line with a cir-
cular stapler device was developed by Longo.37 This
technique, which does not damage the sensitive epithe-
lium of the haemorrhoid,53 is based on the previously
reported stapled rectal mucosectomy.54 This approach
has proven to be effective with minimal pain and is
therefore preferable to conventional haemorrhoid­
ectomy in the treatment of grade III haemorrhoids.55–57
Despite an increased cost of the procedure58 and some
rare but severe (sometimes life-threatenin­g) complica-
tions,59–60 several RCTs,61–65 long-term reports66–68 and
meta-analyse­s69–71 have demonstrated its utility in the
management of grade III haemorrhoids; a 10–25% recur-
rence rate and the safety of this approach have now been
recognized by NICE.72
Stapled haemorrhoidopexy has been compared
favourably with the Milligan–Morgan operation in
terms of postoperative pain and patients’ recovery, but
with a considerably higher risk of recurrence (RR 2.29).72
This procedure, however, should be applied only to
circumferential grade III haemorrhoids when associ-
ated with a rectal internal mucosal prolapse, and per-
formed by well-trained surgeons, as the occurrence of
compli­cations (including rectovaginal fistulas, 73 rectal
obliteration,74 retroperitoneal massive bleeding 75 and
rectal pocket syndrome76) can make the outcome of this
o­peration a nightmare.
Recurrence after stapled haemorrhoidopexy
To overcome the increased recurrence rate reported
after stapled haemorrhoidopexy several attempts have
been made to modify the technique or the device itself.
In brief, stapled haemorrhoidopexy involves the place-
ment of a purse-string suture in the anorectal mucosa
3–4 cm above the dentate line, the placement of the head
of the 33 mm stapler above it, the closure of the purse-
string around the stiff of the stapler and the firing of
the stapler, which results in resection–anastomosis of the
mucosa. Assuming that the reason for recurrence was an

inadequate mucosa resection because of the amount of
the prolapse and/or inadequate room in the case of the
stapler, Pérez-Vicente et al.77 tried to incorporate a larger
quantity of mucosa by performing two purse-strings
instead of the usual one.
Other researchers applied the stapled transanal rectal
resection (STARR) procedure that uses two PPH01
s­taplers.78 The STARR operation was designed for treat-
ing obstructed defecation more than haemorrhoids
and involves a full thickness rectal resection using two
staplers, one for the anterior and one for the posterior
rectal wall. The rectal resection is obtained by placing
2–4 semi-circumference purse-string sutures and pulling
them into the case of the stapler, which is then fired.
This procedure has also been modified into a so-called
parachute technique, which involves the placement of
six separated stitches (instead of a purse-string suture)
on the prolapsed anorectal mucosa; the suture threads
are used to pull the mucosa into the case of the stapler,
which is then fired.79 In 2012, an RCT80 demonstrated
that a new device with a larger case was able to resect a
greater quantity of mucosa compared with the traditional
PPH01 stapler.
Grade IV: surgical treatment
The optimal surgical management of grade IV haemor-
rhoids according to the advice of several national guide-
lines35,81 is excisional haemorrhoidectomy. Although
several excisional techniques have been proposed in
the past (submucosal haemorrhoidectomy according
to Parks,82 circular haemorrhoidectomy according to
Whitehead83), the one proposed by Milligan and Morgan
in 193684 is still the most widely performed technique
(even for grade III haemorrhoids, as discussed earlier)
because of its reproducibility and low recurrence rate
(Box 2).85 Actually, haemorrhoidectomy is the only way
to fix an irreducible haemorrhoidal prolapse together
with the frequently associated hypertrophic skin tags.
However, this operation has some drawbacks, includ-
ing the removal of part of the sensitive anoderm (which
is replaced by scar tissue) and the intense and pro-
longed postoperative pain, which causes a long period
off work for many patients. Of note, the most impor-
tant c­o mplications are postoperative bleeding and
anal stricture.86
Several technical changes have been introduced in
an attempt to prevent or to minimize these drawbacks.
Ferguson87 in 1959 proposed the closure of the remain-
ing anal mucosa to cover the anal wounds and this
type of operation is favoured in North America. Few
studies have compared the Ferguson with the Milligan–
Morgan haemorrhoidectomy, but one of the most recent
was conducted in 2000 88 and demonstrated that the
healing time of anal wounds was substantially faster
after Ferguson’s procedure; no differences in the level
of anal pain were found between the two techniques.
Ferguson haemorrhoidectomy was also demonstrated
to be superior to Milligan–Morgan haemorrhoid­
ectomy in regards to long-term anal continence and
patient satisfaction. 89 Another study also found that
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Box 2 | Surgical procedures for grade IV haemorrhoids
■■ Parks submucosal haemorrhoidectomy82
■■ Whitehead haemorrhoidectomy83
■■ Milligan–Morgan open haemorrhoidectomy using
diathermy with pedicle ligation84
■■ Milligan–Morgan open haemorrhoidectomy using
diathermy without pedicle ligation91
■■ Ferguson closed haemorrhoidectomy87
■■ Milligan–Morgan open haemorrhoidectomy using
harmonic scalpel92
■■ Milligan–Morgan open haemorrhoidectomy using
radiofrequency energy device96
closed haemorrhoidectomy (Ferguson) gave mark-
edly less pain and faster healing compared with open
haemorrhoid­ectomy (Milligan–Morgan), whereas the
rates of re­currence and complications were similar.90
Another operative detail involved in pain control
after Milligan–Morgan haemorrhoidectomy concerns
the ligation of the vascular pedicle, indicated as one
of the causes of postoperative pain. An RCT91 con-
firmed that pedicle coagulation gave markedly less post­
operative pain when compared with pedicle ligation.
The procedure was originally performed by scissors and
later by diathermy or bipolar scissors. In the past few
decades new devices based on ultrasonography or radio­
frequency energy have become available. A double-blind
RCT showed that harmonic scalpel (ultra­sonography)
reduced postoperative pain considerably more than
a scissor-ligation technique and bipolar scissors. 92
However, radiofrequency vessel sealing devices have
been shown to cause less postoperative pain than har-
monic scalpel.93 Several RCTs and a meta-analysis com-
pared radiofrequency devices with a standard diathermy
Milligan–Morgan procedure, showing that these new
devices can considerably reduce operative time, bleeding
and postoperative pain (evidence level I).94,95 A Cochrane
review of 12 RCTs including 1,432 patients confirmed
that the use of radiofrequency devices caused markedly
less postoperative pain, was faster and led to an earlier
return to work than conventional haemorrhoidectomy;
the complication rate and length of in-hospital stay were
similar after the two procedures.96
Post-haemorrhoidectomy pain
In the hope of minimizing post-haemorrhoidectomy
pain, some new minimally invasive techniques were pro-
posed, but both DGHAL with mucopexy 97 and stapled
haemorrhoidopexy 98 were found to be i­ nappropriate
for grade IV haemorrhoids, owing to an unaccept­
able recurrence rate of 29% and 59%, respectively, and
high re-intervention rates. Furthermore, a number of
local treatments were suggested including the use
of m­e tronidazole 99 or topical sucralphate, 100 assum-
ing that postoperative infection and inflammation
were the cause of pain. The use of metronidazole (by
local or general administration) is controversial. 101–104
Topical diltiazem,105 lateral internal sphincterotomy,105
bot­u linum toxin intrasphincteric injection 106 or
­gly­cerin trinitrate ointment 107 have also been proposed,
REVIEWS
supporting the idea that anal post­operative hypertonia
is the true cause of post­operative pain. Finally, new local
analgesics108 and the use of phlebo­tonics have been tested
successfully in patients and are commonly recommended
in clinical practice.109
Special conditions
Pregnancy
Hormonal changes together with vein dilatation and
increased intra-abdominal pressure promote the occur-
rence of haemorrhoids in pregnancy, particularly during
the third trimester and post-partum in 25–30% of preg-
nant women.110–112 Despite their common occurrence, the
literature on their treatment is scarce and the treatment
options are limited by the risk of damaging the foetus.
First-line treatment is conservative (through dietary
modifications, topical or oral drugs) as, in the majority
of cases, haemorrohoids tend to solve after delivery.113
One review 111 suggested that flavonoids (rutosides, for
example) could be effective, although only two RCTs
(including a total of 150 women) have compared the
effect of rutosides with placebo.114–115 One of the studies
reported that rutosides were effective in managing
both the clinical signs and symptoms of haemorrhoids
in pregnancy,114 whereas the other concluded that the
symptoms were better controlled in the rutosides group
compared with the placebo group, but found no changes
in the clinical signs.115
Topical treatment is based on the use of local
a­naesthetics, anti-inflammatory agents and cortico­
steroids, alone or in combination. Observational studies
confirmed their efficacy on haemorrhoid symptoms in
pregnancy (pain, discomfort, bleeding) in the short-
term and also their foetal safety,116,117 but no RCTs have
been performed. Surgery should be avoided in preg-
nant women, above all because spontaneous recovery
of haemorrhoids is expected after pregnancy and post-
partum; when it becomes necessary, after conservative
treatment failure, less invasive treatments are suggested.
In cases of external thrombosis prolapse, local excision
should be avoided.118
Crohn’s disease
The literature on this topic is scarce and dated. In the clin-
ical management of these patients, the first point should
be to determine whether there is any perineal involve-
ment of the disease or not. In patients with haemor­rhoids
and perineal Crohn’s disease, any aggressive treatment
should be discouraged as it can lead to severe compli-
cations that sometimes require proctectomy. 119 One
paper 120 investi­gating the treatment of haemorrhoids with
DGHAL reported good results, but only in patients
with Crohn’s disease without perineal disease.
HIV infection
Proctological diseases including haemorrhoids are
frequent in patients with HIV; however, indications
for surgical management of haemorrhoids in these
patients must be selective because of an increased risk
of infection and delayed wound healing. One of the few
518  |  SEPTEMBER 2013  |  VOLUME 10  www.nature.com/nrgastro
© 2013 Macmillan Publishers Limited. All rights reserved
papers on this topic,121 in fact, demonstrated a substan-
tial delay in wound healing time in HIV and acquired
immunodeficiency syndrome. An antibiotic prophylaxis
is mandatory.
Thrombosed piles
Although it is one of the most frequent proctological
emergencies, the literature on the management of throm-
bosed haemorrhoids is scarce and of a poor level of evi-
dence. The management of thrombosis of the external
subcutaneous haemorrhoid plexus should be kept sepa-
rate from the exteriorized internal haemorrhoid throm-
bosis as they can be easily treated in outpatients under
local anaesthesia.
One of the largest (1,184 patients) retrospective
trials122 comparing urgent closed haemorrhoidectomy
with elective treatment concluded that the more aggres-
sive surgical approach might be a preferable option for
these patients. An important factor to be considered
in clinical decision-making on thrombosed piles is
the risk of recurrence after conservative medical treat-
ment. In a retrospective trial123 comparing a conserv­
ative and a surgical approach with a mean follow-up
of 7.6 months, the mean time for symptom resolution
was 24 days in the conservative group compared with
3.9 days in the surgical group (P <0.0001) and the rate of
recurrence was substantially higher in the conservative
group. The authors of this study therefore concluded that
although haemorrhoid symptoms will resolve in most
patients treated conservatively, the surgical excision of
thrombosed external haemorrhoids leads to more rapid
symptom resolution and lower incidence of recurrence.
A review of the medical literature from 2013 on the man-
agement of external haemorrhoid thrombosis only found
two prospective studies and two retrospective studies.124
These studies showed that surgical excision markedly
relieves symptoms by postoperative day 4 compared
with incision or topical glyceril trinitrate (level IB evi-
dence). In conclusion, surgery seems to be superior to
conservativ­e treatment.
Conclusions
Nowadays, the most accredited theory about the
a­e tiology and pathophysiology of haemorrhoids is
the sliding mucosa theory caused by extracellular
matrix degradation and favoured by constipation.
Therefore, any treatment aiming to facilitate d­efecation
can help the majority of these patients. Phlebotonic
agents can also decrease the risk of bleeding. According
to evidence-based medicine, rubber band ligation can
effectively treat the early stages of the disease whereas
surgery is required for the most advanced stages. Several
effective and safe treatments can be offered to patients
with grade III haemorrhoids, from the classic Milligan–
Morgan haemorrhoidectomy (better when performed
with vessel-sealing radiofrequency energy devices),
to stapled mucopexy, or simple mucopexy with or
without DGHAL (Figure 1). Each of these treatments
have advantages and drawbacks. The most aggressive
approach has the lower recurrence rate but the higher
 REVIEWS

postoperative pain, the less aggressive one has the lower
pain but the higher recurrence rate. Attempts to mitigate
these problems have been proposed including several
operative details and medical treatments to control
p­ostoperative pain and new devices to reduce the recur-
rence rate by resecting a larger amount of mucosal pro-
lapse. In conclusion, surgery for haemorrhoids should
be tailored to both the disease severity and the patient
condition and a good surgeon should be able to choose
the best technique for their patient.
Review criteria
This narrative review was based on the search and
analysis of full-text articles selected by PubMed in the past
30 years using the following MeSH Editing: “hemorrhoids”,
“stapled hemorrhoidopexy”, “anopexy”, “mucopexy”,
“Doppler guided hemorrhoid artery ligation”, “Crohn”,
“HIV”, “pregnancy”, “thrombosed hemorrhoids”, “Milligan–
Morgan”, “Ferguson”, “randomized trials”, “radiofrequency”,
“harmonic scalpel”, “postoperative complications” and
“postoperative pain” alone and in combination.

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REVIEWS
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Author contributions
Both authors contributed equally to all aspects
of this article.