Complaints secondary to hemorrhoidal disease have been treated by health care providers for centuries. Most symptoms referable to hemorrhoidal disease can be managed nonoperatively. When symptoms do not respond to medical therapy, procedural intervention is recommended. Surgical hemorrhoidectomy is usually reserved for patients who are refractory to or unable to tolerate office procedures. This article reviews the pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints.
Key points
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Most hemorrhoidal complaints can be managed nonoperatively.
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Symptomatic internal hemorrhoids typically cause rectal bleeding.
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Symptomatic external hemorrhoids typically cause thrombosis and pain.
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Providers should be familiar with several different techniques to address hemorrhoidal complaints.
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Rubber band ligation is generally helpful in addressing hemorrhoidal bleeding that has not improved with nonoperative treatment.
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Excisional hemorrhoidectomy is effective in managing prolapsing or recurrent hemorrhoidal disease.
Introduction
Complaints secondary to hemorrhoidal disease have been treated by health care providers for at least 4000 years ( Table 1 ). John of Ardene (1307–1390), a surgeon in the English Middle Ages, reportedly stated: “The common people call them piles, the aristocracy call them hemorrhoids, the French call them figs—what does it matter so long as you can cure them?” Most hemorrhoidal presentations can be managed nonoperatively. When hemorrhoidal symptoms do not respond to medical therapy, procedural intervention is recommended. A firm grasp of anorectal anatomy is essential for choosing the appropriate method of treatment. This article reviews the anatomy and pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints.
| Location/Size | Symptoms | |
|---|---|---|
| First degree | Bulge into anal canal | Painless bleeding |
| Second degree | Exit the anal canal with defecation Reduce spontaneously | Painless bleeding Pruritus |
| Third degree | Prolapse from anal canal with defecation Require manual reduction | Painless bleeding Pruritus Mucous/fecal leakage |
| Fourth degree | Permanent prolapse from anal canal Not reducible | Pain Bleeding Mucous/fecal leakage |
Introduction
Complaints secondary to hemorrhoidal disease have been treated by health care providers for at least 4000 years ( Table 1 ). John of Ardene (1307–1390), a surgeon in the English Middle Ages, reportedly stated: “The common people call them piles, the aristocracy call them hemorrhoids, the French call them figs—what does it matter so long as you can cure them?” Most hemorrhoidal presentations can be managed nonoperatively. When hemorrhoidal symptoms do not respond to medical therapy, procedural intervention is recommended. A firm grasp of anorectal anatomy is essential for choosing the appropriate method of treatment. This article reviews the anatomy and pathophysiology of hemorrhoidal disease and the most commonly used techniques for the nonoperative and operative palliation of hemorrhoidal complaints.
| Location/Size | Symptoms | |
|---|---|---|
| First degree | Bulge into anal canal | Painless bleeding |
| Second degree | Exit the anal canal with defecation Reduce spontaneously | Painless bleeding Pruritus |
| Third degree | Prolapse from anal canal with defecation Require manual reduction | Painless bleeding Pruritus Mucous/fecal leakage |
| Fourth degree | Permanent prolapse from anal canal Not reducible | Pain Bleeding Mucous/fecal leakage |
Anatomy and pathophysiology
Hemorrhoids are specialized, vascular cushions located in the anal canal. Hemorrhoids are typically clustered into three anatomically distinct cushions located in the left lateral, right anterolateral, and right posterolateral anal canal ( Fig. 1 ). They are found in the submucosal layer and are considered sinusoids because they do not typically have a muscular wall. Hemorrhoids are held in the anal canal by Treitz muscle, a submucosal extension of the conjoined longitudinal ligament. The fibers seem to act as a support lattice not only for hemorrhoids but for other important structures in the anal canal. Some authors have reported a loss of these support structures with aging, perhaps explaining the increased incidence of hemorrhoidal complaints with age.
Hemorrhoidal structures are typically described as internal hemorrhoids or external hemorrhoids. Internal hemorrhoids are proximal to the dentate line and have visceral innervation. For this reason, internal hemorrhoids generally do not present with pain as an initial complaint. More often, patients with internal hemorrhoids complain of painless bleeding. Internal hemorrhoids generally are spanned by the anal transitional zone, and therefore can be covered by columnar, squamous, or basaloid cells. External hemorrhoids are located below the dentate line in the distal third of the anal canal. External hemorrhoids are covered by anoderm (squamous epithelium). Because of their somatic innervation, external hemorrhoids are more likely to present with pain.
Hemorrhoids are thought to enhance anal continence and may contribute 15% to 20% of resting anal canal pressure. They also complete closure of the anus and may enhance control of defecation. Because hemorrhoids have sensory innervation, they also relay important data regarding the quality and composition (gas, liquid, stool) of intrarectal contents.
Because hemorrhoids represent collections of sinusoids, intra-abdominal pressure phenomena are easily manifested. Development of hemorrhoidal disease is likely associated with activities that increase in intra-abdominal pressure. This increase may be secondary to straining, excessive time spent on the toilet, or constipation. Other etiologic factors that can cause hemorrhoidal irritation include diarrhea and dehydration. Women in the third trimester of pregnancy commonly report hemorrhoidal swelling caused by increased intravascular volume and the estrogen sensitivity of hemorrhoidal tissues.
Physical examination
Patients with anorectal complaints should be examined in a comprehensive and systematic fashion. The examination begins with inspection of the perianal skin. Often this is the only examination necessary because the pathology may be evident on the perianal skin. Often thrombosed external hemorrhoids are evident externally and can be identified because they are covered with anoderm. They commonly have a hint of visible clot underneath the surface of the anoderm ( Fig. 2 ). These can be differentiated from prolapsed internal hemorrhoids, which are not covered with squamous epithelium, but rather columnar mucosa ( Fig. 3 ).
Digital rectal examination can exclude the presence of palpable masses within the anal canal. Valuable information about the tone, contractile strength, and bulk of the anal sphincter mechanism can also be gained through digital examination.
Anoscopy is usually performed to inspect the anal canal mucosa and can often identify thrombosed internal hemorrhoids, fissures, condyloma, and the internal openings of fistula tracts, among other anorectal pathology. Rigid or flexible proctoscopy can evaluate the rectum for more proximal causes of bleeding, such as proctitis or rectal neoplasms.
Hemorrhoidal classification
Hemorrhoids are normal structures and therefore they are only treated if they become symptomatic. They are commonly classified as first-, second-, third-, or fourth-degree hemorrhoids. First degree hemorrhoids simply represent hemorrhoids bulging into the anal canal but not out of the anal canal. Patients with this level of hemorrhoidal disease typically present with painless bleeding. Often this can be recurrent and ephemeral, occurring on a few selected days over the course of months.
Second-degree hemorrhoids are hemorrhoids that prolapse out of the anal canal with defecation but spontaneously reduce. Patients with second-degree hemorrhoids often complain of painless bleeding and perianal itching caused by chronic moisture secreted by the anal canal mucosa.
Third-degree hemorrhoids represent hemorrhoids that have prolapsed out of the anal canal and that require manual reduction. Often patients need to reduce the hemorrhoids several times per day or after every bowel movement. Patients with third degree hemorrhoids may report a history of bleeding with defecation; pain (likely caused by local ischemia); and mucus drainage.
Fourth-degree hemorrhoids are commonly referred to as incarcerated hemorrhoids ( Fig. 4 A ). In this situation, hemorrhoids are permanently prolapsed outside of the anal canal and cannot be reduced manually. These patients typically present with bleeding and severe pain or discomfort. Many patients in this category require urgent surgical intervention ( Fig. 4 B).
Nonoperative treatment
Diet and Lifestyle Modifications
First- and second-degree hemorrhoidal disease can generally be treated with nonoperative measures. The primary goal of nonoperative treatment is to reverse the pathophysiologic trigger of hemorrhoidal disease and to reduce symptoms. In most patients, this therapy involves reduction of the intra-abdominal pressure transmitted to the hemorrhoidal vessels during bowel movements. Some patients require adjuncts to investigate unexplained constipation or diarrhea, which may have stimulated hemorrhoidal disease.
The mainstay of nonoperative hemorrhoidal treatment is to increase fiber and water consumption. Several studies document that fiber supplementation can reduce symptoms and bleeding, although this effect may take several weeks to manifest. Patients should also be counseled on other lifestyle modifications, including the avoidance of prolonged sitting or straining on the toilet, perianal hygiene, and avoiding triggers of constipation or diarrhea.
Topical and Oral Agents
There are several over-the-counter medications that purport to reduce hemorrhoidal symptoms. Most of these treatment are aimed at providing symptomatic relief rather than truly altering the underlying pathophysiology of the disease. The various preparations include several medications including local anesthetics, vasoactive agents, corticosteroids, antibiotics, and lubricants. Although these treatments are plentiful, data regarding their efficacy are sparse.
Vasoconstrictive medications can be applied to the anal canal to alter the vascular channels supplying the hemorrhoidal tissues. Vasocontriction would theoretically reduce the size and perhaps secretions from hemorrhoidal tissues. One widely available commercial example is Preparation-H (Pfizer). This medication consists of petroleum, mineral oil, and 0.25% phenylephrine.
Other authors have described effective use of nitrates for patients with hemorrhoids and elevated anal canal pressures. Although effective, treatment with topical nitrates was associated with a high incidence of nitrate-associated headaches. Patients with acutely thrombosed internal or external hemorrhoids can sometimes be treated with topical calcium channel blockers, such as nifedipine. These agents likely reduce spasm in the internal sphincter leading to manual or autoreduction of hemorrhoidal tissues.
Calcium dobesilate is a vaosactive drug used in the management of diabetic retinopathy and venous insufficiency. Calcium dobesilate’s mechanism of action is thought to be related to decreasing tissue edema by altering vascular permeability and platelet aggregation. Menteş and colleagues randomized 29 patients with symptomatic hemorrhoids to calcium dobesilate and a high-fiber diet or to a high-fiber diet alone. Eighty-six percent of patients treated with calcium dobesilate described cessation of bleeding and improvement in perianal irritation.
Oral flavinoids are also used in the management of hemorrhoidal disease. Flavinoids are a class of venotonic agents that also can alter vascular permeability and reduce tissue edema. Their mechanism of action is unclear but they are used in Europe and Asia for the treatment of hemorrhoidal disease. A recent Cochrane review examined the use of oral phlebotonics including flavinoids and calcium dobesilate in the management of hemorrhoidal disease. Phelobotonics exhibited a remarkable treatment effect in favor of their use when the outcomes of pruritus, bleeding, discharge or leakage, and overall symptom improvement were compared with a control group. These compounds have not gained wide acceptance in the United States.
Office Procedures
Several office procedures are available for the management of symptomatic hemorrhoids. These include infrared coagulation, sclerotherapy, cryotherapy, and rubber band ligation. All of the available techniques rely on tissue destruction and resultant tissue fixation caused by fibrosis.
Rubber band ligation
Rubber band ligation is most often used to treat first- and second-degree hemorrhoids. Certain third-degree hemorrhoids also can be treated with rubber band ligation. A rubber band is placed around the hemorrhoid above the dentate line ( Fig. 5 ), causing localized ischemia in the intervening tissue. A portion of the hemorrhoid and the rubber band are passed in several days during defecation. The resultant fibrosis causes fixation of the remaining hemorrhoidal tissues. This prevents further prolapse and bleeding.
