A 30-year-old man presents with complaint of intermittent anal bleeding. He relates occasional bright red blood staining his toilet paper after wiping. He denies pain or tenderness. He denies any change in his bowel habits. When asked about his diet, he describes fast-food meals and snacks. He admits to playing games on his iPad during bowel movements.

He presents with a normal external anal opening. Upon rectal examination, columnar fullness is appreciated in the left lateral position. Anoscopy reveals prominent columnar engorgement above the dentate line circumferentially. No evidence of ongoing bleeding. No significant tenderness with examination. After withdrawing the anoscope, he is asked to bear down—no protrusion of tissue from within the anal canal.

Grade 1 internal hemorrhoids

Early hemorrhoid disease will frequently present as painless bleeding noted as streaking on toilet paper. It is important to differentiate hemorrhoids from other pathological conditions including fissure, polyps, IBD, or cancer. It is uncommon for bleeding hemorrhoids to present with anemia and all other conditions should be ruled out prior to treating the hemorrhoids. As stated earlier, hemorrhoidal grading is determined by protrusion. Enlarged hemorrhoids that do not protrude below the dentate line are considered grade 1. Factors leading to development of hemorrhoids include hard stools from a low-fiber diet, limited fluid intake, straining to pass bowel movements, and prolonged sitting during bowel movements. With distention of the hemorrhoid vessels within the anal canal, irritation from passage of stool and wiping can lead to excoriation and bleeding. As the anoderm above the dentate line is largely insensate, patients will not present with pain as an initial symptom.

Initial treatment of grade 1 hemorrhoids consists of lifestyle modification focused upon the causative factors identified above. Patients are encouraged to increase dietary fiber and fluid intake either through meal selection or supplements. This will improve stool bulk to provide softer bowel movements and limit straining. Behavior modification focuses upon time spent sitting in the bathroom. If unable to pass a bowel movement after 2 min on the toilet, patients should be encouraged to leave the bathroom and reattempt at a later time. Additionally, the use of hydrocortisone either topically or in suppository form may result in decreased swelling, while behavior modification is implemented. These conservative measures are successful in the majority of patients and prevent progression of hemorrhoid disease. For patients who continue to have bleeding despite these changes when all other causes have been eliminated, interventions such as rubber band ligation, sclerotherapy, and infrared photocoagulation can be used.

A 52-year-old male presents with a history of bright red blood per rectum. The patient reports blood dripping in the toilet as well as on the toilet paper with bowel movements. He can feel swelling at his backside that subsides about 30 min after defecation; he occasionally will need to push on the swelling to achieve resolution. He has a history of congestive heart failure treated with diuretics and seasonal allergies treated with intermittent antihistamines. He reports regular bowel movements and does not strain on the toilet. His wife reports that he will sometimes spend 15–20 min in the bathroom.

Grade 2/3 internal hemorrhoids

Progression of hemorrhoid disease to grade 2 or 3 is defined by protrusion of internal hemorrhoids below the dentate line with spontaneous reduction in grade 2 or manual reduction in grade 3 (Fig. 10.3). Again, painless bleeding will frequently be a patient’s presenting complaint, but with advance hemorrhoids the feeling of a mass or swelling is common. For some patients, pruritus ani will develop when protrusion of hemorrhoid tissue allows seepage of rectal contents through the anal sphincters leading to irritation and inflammation of the sensate squamous epithelium below the dentate line.

Initial treatment of grade 2 internal hemorrhoids follows the dietary and behavioral modification outline for grade 1 disease. Additionally, patients with grade 2 or 3 hemorrhoids are encouraged to soak in a warm tub or even apply ice packs to their perianal area. There is no strong evidence to support this practice, but many patients report significant relief of their symptoms with this treatment option. For patients refractory to dietary and behavioral modification, rubber band ligation of the internal hemorrhoids in the clinic setting provides a simple and elegant solution.

First described in 1963 by Barron, banding is performed during anoscopy [5]. Conventional banding uses an atraumatic clamp and a bander to deploy a rubber band gathering redundant mucosa above the hemorrhoidal column. A purpose-built suction bander serves a similar function and can be operated with one hand. The bander is placed within the anal canal above the prominent hemorrhoid column. The anorectal mucosa is drawn into the device. A trigger deploys the rubber band to permanently gather this tissue. Banding proximally tethers the hemorrhoid columns within the anal canal preventing protrusion. Over the following 3–5 days, the banded tissue will strangulate, necrose, and pass with a bowel movement occasionally heralded by a brief episode of self-limited bleeding. Most patients can achieve cure with this intervention at success rates of 75% [6] (Figs. 10.4 and 10.5). Some patients may require repeat banding depending on the severity of their hemorrhoids. Recurrence is prevented by continued adherence to dietary and behavioral modifications. Complications of rubber band ligation include pain, thrombosis, bleeding, and potential life-threatening pelvic sepsis. In our experience, most patients will experience a dull ache for 24–48 h. Symptomatic relief is provided by Tylenol or ibuprofen and sitting in a warm tub. Any patient who develops urinary retention with severe pelvic pain and fever should be promptly evaluated for pelvic sepsis. Early intervention with possible removal of the band, IV antibiotics, and careful observation are important steps to prevent further complications.

Another option for treatment of grade 2 or 3 hemorrhoids is sclerotherapy . Historically, this was performed prior to the advent of rubber band ligation. This process involves injection of a caustic agent to decrease the blood flow and induce fibrosis. Many different solutions have been used for sclerotherapy, but most clinicians now use a commercially available 5–10 % phenol solution with oil. Using a 25-gauge needle, the submucosa 1 cm above the dentate line is infiltrated with 1–2 mL of solution. Long-term results are very similar to banding in grade 1 and 2 hemorrhoid patients [7].

Infrared photocoagulation (IRC) is another less frequently used option for the treatment of hemorrhoids. IRC uses infrared light to generate heat which coagulates tissue proteins and evaporates water from cells. This leads to inflammation and scarring providing fixation of the hemorrhoid and treating the prolapse. IRC has been shown to work best with grade 1 and 2 hemorrhoids [7].

For 5–10 % of patients, failure of medical and noninvasive treatment will require a formal excisional hemorrhoidectomy. Indications for hemorrhoidectomy include grade 3 or 4 hemorrhoids with severe symptoms, concomitant anorectal disease requiring surgery, or patient preference. The two most described surgical procedures are the open Milligan-Morgan hemorrhoidectomy and the closed Ferguson hemorrhoidectomy. A multitude of descriptions and modalities for these procedures exist—each with similar outcomes. Briefly, tenants of the procedures will include ligation of the vascular pedicle above the hemorrhoid column, excision of the hemorrhoid tissue, and either closure of the anal mucosa defect or healing by secondary intention [8]. Classically, this procedure has been performed with either scalpel or electrocautery, but some clinicians prefer to use either the harmonic scalpel (Ethicon Endo-Surgery, Cincinnati, OH) or the LigaSure (Covidien, Boulder, CO). Most studies have shown no difference in healing rates or pain ratings with these newer devices. As a benefit, they can reduce operating room time and have less bleeding associated with their use [9]. Complications of surgical hemorrhoidectomy include pain, bleeding (0.3–6 %), anal stenosis (0–6 %), urinary retention (2–36 %), and incontinence (2–12 %).

Because pain is the largest barrier to hemorrhoid surgery, many new devices have come to market which purport to give the same long-term improvement in symptoms with less post-procedural pain. These include Doppler-guided transanal hemorrhoid devascularization (THD™, AMI™), stapled hemorrhoidectomy or procedure for prolapsed hemorrhoids (PPH), and the hemorrhoid energy therapy (HET™) bipolar system.

The transanal hemorrhoid devascularization technique first described by Morinaga et al. in 1995 involves ligation of each of the six feeding vessels of the hemorrhoidal columns. The vessels are identified with a Doppler probe and ligated with an absorbable suture like Vicryl. A prolapsed hemorrhoid is then reposited to its formal location by pulling it up with a similar suture which starts at or above the ligation site and ends just above the dentate line. Results with the procedure are favorable with recurrence rates at 1 year around 10–15 % [10].

The stapled hemorrhoidectomy was introduced for hemorrhoids in 1998. First, an anal dilator is used to secure a circumferential purse-string stitch 2–4 cm above the dentate line. A modified EEA stapler is then inserted into the anal canal and the purse-string stitch draws redundant mucosa into the head of the stapler. The stapler is then fired excising a ring of redundant tissue and creating a circumferential staple line above the dentate line. Most long-term studies show no difference in pain when compared to conventional hemorrhoidectomy, but recurrence rates appear to be higher. Additionally, there are several unique complications associated with stapled hemorrhoidectomy including fistula, staple-line bleeding, and chronic pain [11].

The HET bipolar system represents the newest procedure to be employed for hemorrhoidal disease. Introduced in 2014, hemorrhoid energy therapy involves a patented anoscope with a window through which the hemorrhoidal tissue is isolated. Closing and activating the device around the hemorrhoid heats the submucosal vessels to induce coagulation and decreased blood flow. Early reports are encouraging with minimal pain and good short-term results, but to date no long-term studies have been performed.