7.3.1 Prevalence

Assessing the true prevalence of hemorrhoids is virtually impossible, with reported prevalence rates varying from 1 to 86%, depending on the method of ascertainment and the definition of “hemorrhoids.” ⁸ Using the data from the National Center for Health Statistics, Johanson and Sonnenberg found that 10 million people in the United States complained of hemorrhoids, a prevalence rate of 4.4%. ⁹ Of them, approximately one-third went to a physician for evaluation, and an average 1.5 million prescriptions were written annually for hemorrhoidal preparations. The rate of hospitalization for patients with hemorrhoids was 12.9 per million people. The age distribution of hemorrhoids demonstrated a hyperbolic pattern, with a peak between age 45 and 65 years and a subsequent decline after age 65 years. The presence of hemorrhoids in patients younger than 20 years old was unusual. ⁹ All these figures could have been easily exaggerated, since they are based on complaint. Obviously, not all the complaints are true hemorrhoids.

National Hospital Discharge Survey data indicate that, on average, 49 hemorrhoidectomies per 100,000 people in the United States were performed annually from 1983 to 1987. Hemorrhoidectomies are performed 1.3 times more commonly in males than in females. Most hemorrhoidectomies are performed in patients 45 to 64 years old. According to National Hospital Discharge Survey data, a threefold decrease in the number of hemorrhoidectomies is observed, from a peak of 117 per 100,000 in the United States in 1974 to a low of 37 per 100,000 in 1987. ¹⁰ This decline may not reflect a decrease in the occurrence of hemorrhoidal disease, but may be a response to the increase in nonoperative and outpatient procedures.

7.3.2 Etiology

Enlargement or pathologic changes in hemorrhoidal tissue result in symptoms of the “hemorrhoidal syndrome.” Proposed etiologic factors for these changes include constipation, prolonged straining, pregnancy, and derangement of the internal sphincter. ² Constipation and the associated straining with defecation, as suggested by Burkitt and Graham-Stewart, ¹¹ are related to eating habits, specifically to a low-residue diet. The typical American low-fiber diet may explain the high prevalence of constipation, straining, and hemorrhoidal symptoms in America. ¹² With time (aging), the anatomic structures supporting the muscularis submucosae weaken, which leads to slippage or prolapsing of the hemorrhoidal tissue. Haas et al confirmed microscopically that anal supporting tissues deteriorate by the third decade of life. ¹³ Finally, many studies have consistently shown higher anal resting pressures in patients with hemorrhoids. ^{14 , 15 , 16} An increase in resting pressure is reduced to normal after hemorrhoidectomy. Internal sphincter, external sphincter, and pressure within the anal cushions can all account for the increased resting tone. However, it is not possible to distinguish their contributions. ^{17 , 18} Patients with enlarged hemorrhoids have been found on electromyography to have increased activity. ¹⁸ Another abnormality found in many of these patients is an ultraslow pressure wave caused by the contraction of the internal sphincter as a whole, but its significance is not known. ¹⁸ Anal electrosensitivity and temperature sensation are reduced in patients with hemorrhoids. The greatest change is noted in the proximal anal and midanal canals, perhaps because of prolapse of the less-sensitive rectal mucosa. This may also contribute to decreased continence. Rectal sensation to balloon distention is no different from that observed in control subjects. ¹⁹

Although chronic constipation has been considered the cause of hemorrhoids, Gibbons et al cast doubt on this hypothesis. ²⁰ Their studies show that patients with hemorrhoids are not necessarily constipated but tend to have abnormal anal pressure profiles and anal compliance. It is well known, however, that constipation aggravates symptoms of hemorrhoids. A case–control study on the risk factors for hemorrhoids by Johanson and Sonnenberg questions the influence of chronic constipation but supports diarrhea as a potential risk factor. ²⁰ The tenesmus from diarrhea does cause straining.

Many other factors have been implicated in the causation of hemorrhoidal disease, notably heredity, erect posture, absence of valves in the hemorrhoidal plexuses and draining veins, and obstruction of venous return from raised intra-abdominal pressure. All these factors may contribute to causing the disease, but these anatomic factors do not account for the differences found in epidemiologic studies. Pregnancy undoubtedly aggravates preexisting disease and, by mechanisms not well understood, predisposes to the development of disease in patients who were previously asymptomatic. Furthermore, such patients usually become asymptomatic after delivery, which suggests that hormonal changes, in addition to direct pressure effects, may be involved.

In addition to the hemorrhoidal plexuses lying superficial to the sphincter mechanism, it has been theorized that a dysfunctional sphincter could lead to venous outflow obstruction and congestion, followed by engorgement of the hemorrhoids and subsequent symptoms. ¹³ All of these conditions contribute toward stretching and slippage of the hemorrhoidal tissue. The overlying skin or mucosa is stretched and additional fibrous and sinusoidal tissue develops. The extra tissue tends to move caudally toward the anal verge, making it susceptible to injury and causing symptoms to develop. A survey into the prevalence of benign anorectal disease demonstrated that 9% of adults had previous treatment of hemorrhoidal disease and 8% had hemorrhoidal symptoms. ¹⁴

Hemorrhoids are not related to portal hypertension. ⁷ With increased portal venous pressure, the body develops portosystemic communications in several locations. In the pelvis, communications enlarge between the superior and middle hemorrhoidal veins, which results in development of rectal varices. These varices are located in the lower rectum, not the anus. Because of the rectum’s large capacity, they rarely bleed. Older literature suggested a relationship between portal hypertension and hemorrhoids partly due to the fact that hemorrhoids are common and therefore many portal hypertensive patients will have hemorrhoids. If portal hypertension was an etiologic factor, hemorrhoidal bleeding would be venous blood rather than arterial bleeding, as described earlier. Hemorrhoidal symptoms may be difficult to manage in patients with portal hypertension as their liver disease frequently is associated with coagulation and platelet problems.

7.3.3 Classification

For anatomic and clinical reasons, hemorrhoidal tissue has been divided into two types: external and internal. External hemorrhoids are located in the distal one-third of the anal canal (distal to the dentate line) and are covered by anoderm (modified squamous epithelium that bears no skin appendages) or skin (▶ Fig. 7.1). As this overlying tissue is innervated by somatic nerves, it is sensitive to touch, temperature, stretch, and pain. Symptoms from external hemorrhoids usually result from thrombosis of the hemorrhoidal plexus. The rapid tissue expansion produced by the clots and edema causes pain. Physical effort is felt to be an etiologic factor in thrombosis of external hemorrhoids. Physical examination reveals one or more tender blue colored masses at the anus; additional symptoms are discussed below.

Internal hemorrhoids are located proximal (cranial) to the dentate line and covered by columnar mucosa or transitional epithelium. Based on size and clinical symptoms, internal hemorrhoids can be further subdivided by grades. ^{2 , 21 , 22 , 23} Grade 1 hemorrhoids protrude into, but do not prolapse out of, the anal canal. Grade 2 hemorrhoids prolapse out of the anal canal with bowel movements or straining, but spontaneously reduce. Grade 3 hemorrhoids prolapse during the maneuvers described above and must be manually reduced by the patient. Grade 4 hemorrhoids are prolapsed out of the anus and cannot be reduced (▶ Fig. 7.1b). Hemorrhoids that remain prolapsed may develop ischemia, thrombosis, or gangrene. Patients may have both internal and external hemorrhoids (mixed or combined; ▶ Fig. 7.1c).

7.4.1 Symptoms

Patients with any anal complaints commonly present to physicians complaining of “hemorrhoids.” Careful exploration of their symptoms will often lead to the correct diagnosis.

Symptoms associated with hemorrhoidal disease include: mucosal protrusion, pain, bleeding, a sensation of incomplete evacuation, mucous discharge, difficulties with perianal hygiene, and cosmetic deformity. General disorders of bowel function such as diarrhea and constipation, and associated disorders such as bleeding problems should be considered. A dietary and medication history should always be taken.

Except when thrombosis or edema occurs, hemorrhoids are painless. Painless bleeding occurs from internal hemorrhoids, is usually bright red, and is associated with bowel movements. The blood will occasionally drip into the commode and stain the toilet water bright red. After trauma by firm stools or forceful bowel movements, bleeding may continue to occur with bowel movements for several days. The bleeding will often then resolve for a variable period of time. It is unusual for hemorrhoidal bleeding to be severe enough to cause anemia but this has been reported to occur in 0.5 patients per 100,000 population. ²⁴

Prolapse may be appreciated by the patient as an anal mass, a feeling of incomplete evacuation, or a mucous discharge. The patient’s requirement to manually reduce prolapsed hemorrhoids should be ascertained. If thrombosis or gangrene occurs, it will be apparent on physical examination and may be associated with systemic symptoms.

7.4.2 Examination

Examination of the anal area is usually undertaken with the patient in a prone position on a special proctologic table. If the patient is elderly or uncomfortable in this position, however, the modified left lateral decubitus (Sims’) position is an acceptable alternative. Inspection of the anus should be done slowly, with calm reassurance by the examiner. The skin about the perineum, genitalia, and sacrococcygeal areas should be scrutinized. Gentle, steady spreading of the buttocks will allow for close inspection of the majority of the squamous portion of the anal canal.

Straining while sitting on the toilet is the useful examination in patients with grades 2, 3, and 4 hemorrhoids. The severity of the prolapse can be easily seen and the degree of descending perineum can be evaluated. It can also differentiate hemorrhoid from rectal prolapse particularly when the true rectal prolapse comes to but not through the anus. By asking the patient to strain while the examiner’s index finger is in the anorectum, an enterocele can be detected.

Digital examination gives the examiner an appreciation for the amount and location of any pain in the anal canal. It enables assessment of the sphincter tone and helps exclude other diseases such as palpable tumors or abscesses in the lower rectum and anal canal. Hemorrhoids are not generally palpable unless quite large or thrombosed.

Anoscopy, usually done with a side-viewing instrument, permits visualization of the condition of the anoderm and internal hemorrhoidal complexes. As the patient strains, the hemorrhoids bulge into the lumen of the anoscope. The degree of prolapse may be assessed by gently withdrawing the anoscope as the patient strains.

Rigid proctosigmoidoscopy and flexible sigmoidoscopy form an important part of the initial examination and are performed to exclude more proximal disease. If the patient is younger than 40 years and hemorrhoidal disease compatible with symptoms is seen on physical examination, most authors feel that no additional workup is required. If the patient is older than 40 years, hemorrhoidal disease is not observed, or additional symptoms are present, a barium enema or colonoscopy is obtained to identify other etiologies for bleeding not observed by the proctoscopy.

7.4.3 Differential Diagnosis

It is extremely important that other causes of bleeding, itching, or discharge be considered, as listed in ▶ Table 7.1. Although patients invariably attribute anal pain to hemorrhoids, acute anal pain is almost always caused by either anal fissure or anorectal abscess. Pain from hemorrhoids occurs only in association with thrombosis or prolapse.

7.5.1 General Principles

Treatments are many and varied, with some treatments, as described earlier, dating back to biblical times. ¹⁷ Modern therapy includes identification and correction of gastrointestinal tract dysfunction, minimization of symptoms, and, in some patients, correction of anal abnormalities, excision of excess hemorrhoidal tissue, and prevention of slippage or prolapse. Treatment can be nonoperative or operative. Nonoperative techniques include dietary modifications, topical medications, and measures (such as sitz baths) to reduce symptoms. Operative techniques, many of which can be performed in an office setting, include tissue fixation, major tissue excision, or physiologic alterations of the anal canal (Lord’s dilation or lateral internal sphincterotomy). The method chosen is usually related to the type of hemorrhoidal tissue causing symptoms, and the experience and judgment of the treating physician. ²

7.5.2 Internal Hemorrhoids Diet and Stool Bulking Agents

Dietary modification is a mainstay for any therapy for hemorrhoidal disease. ²⁵ If the patient is constipated or straining, a diet high in fiber (usually at least 20–30 g/day) with adequate oral fluid intake is recommended, striving for a soft-formed compressible stool that is easy to pass.

This type of stool reduces the requirement to strain with bowel movements and lessens the chance of hemorrhoidal injury. Moesgaard and colleagues ²⁶ conducted a prospective double-blind trial, which demonstrated that psyllium fiber, when added to the diet of patients with anal bleeding and pain with defecation, improved their symptoms over a 6-week period. Patients with diarrhea and hemorrhoidal disease, after an evaluation of the underlying cause of their loose stools, should also receive dietary manipulation with fiber and antidiarrheals as indicated.

Dietary fiber is more appropriately referred to as a stool normalizer rather than a stool softener. It is uncommon for dietary fiber to cause complications, and allergic reactions to the active or inactive ingredients are exceptionally rare. The most common clinical difficulty is noncompliance due to problems with taste or symptoms of bloating and crampy abdominal pain. Fiber products currently available are listed in ▶ Table 7.2. Manufacturers have attempted to improve the palatability of these products in several ways. Adding flavoring and sweeteners has improved taste but usually at a higher cost and less fiber per unit volume. The different fiber sources may produce variable effects in different patients. It is advisable, therefore, to try alternate products if the first selection does not produce the desired results. To minimize symptoms, many providers find it helpful to start patients at a lower dose of the fiber supplement and to slowly increase the amount of fiber ingested until the desired stool consistency is achieved. It is also important to counsel patients to ingest an appropriate amount of water with their fiber, generally 80 to 120 oz (240–360 mL) per day. Fiber consumption of greater than 35 g/day with inadequate water intake can predispose to bezoar formation. Polyethylene glycol supplementation (e.g., Miralax, Bayer Health Care, Whippany, NJ) aids in the retention of water in the stool. It can be helpful in patients who are less compliant with fiber, especially females. If dietary manipulations fail to relieve symptoms, additional therapy is indicated (▶ Table 7.3).

Rubber Band Ligation

Rubber band ligation was originally described by Blaisdell in 1958 ³⁰ and refined and popularized by Barron in 1963. ³¹ Placement of a tight rubber band around excess hemorrhoidal tissue constricts the blood supply to the contained tissue, which sloughs over 5 to 7 days. This leaves a small ulcer which heals fixing the tissue to the underlying muscle. Because of its simplicity, safety, and effectiveness, rubber band ligation is currently the most widely used technique in the United States for treating first-, second-, and some third-degree internal hemorrhoids. ⁵

To accomplish this procedure, informed consent is obtained and an anoscope is inserted into the anus (the author prefers a slotted lighted scope; ▶ Fig. 7.2). A hemorrhoid bundle is identified, and through the anoscope, a band is placed using one of two types of ligators (▶ Fig. 7.3). A suction ligator (McGown, Pembroke Pines, FL) draws the hemorrhoid bundle into the ligator barrel and, closing the handle, places the band around the hemorrhoidal tissue. With a Barron or McGivney ligator (Electro-Surgical Instrument Co, Rochester, NY), an atraumatic clamp (▶ Fig. 7.4) is used to retract mucosa and redundant hemorrhoidal tissue at the apex of the bundle into the applicator and a small rubber band is placed. This tight band causes ischemia of the enclosed tissue. After it necroses, the tissue sloughs, forming a small ulcer. Excess tissue is eliminated, and as healing occurs, the remaining lining becomes fixed in the anal canal. Rubber band ligation works best for grade 2 to 3 internal hemorrhoids.

Several points require additional elaboration. First, it is crucial that the bands be placed on tissue entirely covered by anal mucosa. If bands are placed too distal and include any somatically enervated skin, the patient will develop excruciating pain. The pain is usually so severe that the patient will demand removal of the band. To prevent this from occurring, it is recommended that bands be placed at the apex of the hemorrhoid bundle or just cranial to it. As an additional check, the proposed site of banding is tested by placing a clamp on the mucosa. If the patient feels the pain, the procedure should be abandoned. It is important that the clamp not be pulled after being applied. As the anal and rectal mucosa is sensitive to stretch, traction on the mucosa will produce inappropriate pain.

A second consideration, when using a Barron-type ligator, is to resist too forceful retraction of the hemorrhoidal tissue. If pulled too hard, the hemorrhoidal tissue may be torn, resulting in hemorrhage that is sometimes difficult to control. This type of bander also requires two hands and an assistant to stabilize the anoscope during the procedure. The McGown ligator can be used with one hand, but it is more difficult to control the amount of tissue drawn into the bander. Finally, some providers preload two bands on the applicator to ensure tissue constriction and guard against slippage and breakage. ⁵ Other providers have advocated injecting the pedicle of tissue contained within the band with saline or xylocaine. This injection causes the pedicle to swell, which reduces the chance of the bands slipping off prematurely.

Controversy exists about the appropriate number of hemorrhoidal bundles that can be banded at one session. ³² The author prefers to treat one or two bundles at a time. Banding this number eliminates symptoms in most patients, does not produce too large an amount of banded tissue in the anal canal or cause excessive discomfort, and probably leads to efficient care. ^{33 , 34}

Before leaving the office, patients are instructed both verbally and in writing that after banding they may experience a feeling of incomplete evacuation. The sensation of fullness is from the bunched tissue in the anal canal. If the urge to defecate or urinate is noted, patients are instructed to sit and try to pass the stool. If no stool is produced, they should refrain from prolonged straining. At 5 to 7 days after treatment, the bands and necrotic tissue will slough, which may be associated with a small amount of bleeding. If the symptoms have not resolved at reexamination 2 to 6 weeks later, additional bands are placed. Normal activities can otherwise be resumed immediately after banding.

Complications are infrequent with rubber band ligation (< 2%). ²⁵ They vary from transient problems such as a vasovagal response on placement of the bands, to anal pain, or rarely pelvic sepsis. The vasovagal response to banding includes diaphoresis, bradycardia, nausea, and mild hypotension. Reassuring the patient, elevating their feet, and applying a cold compress to the patient’s forehead are frequently all that is necessary. Symptoms should resolve in 10 to 15 minutes. Despite the rarity of pelvic sepsis, its devastating sequela makes it worthwhile to explain the heralding symptoms as part of the office discharge instructions. Accordingly, patients must know that if the pain increases instead of decreasing or urinary retention or fever develops, they should immediately contact their physician.

Pain occurs due to incorporation of somatically enervated tissue into the band. This occurs when the band is placed too close to the dentate line or the internal sphincter muscle is included into the band (i.e., too much tissue included within the band). In this case, the pain is acute in onset at the time of banding. Mild pain can be managed with analgesics such as propoxyphene napsylate and acetaminophen or injection of a local anesthetic (e.g., 0.5% xylocaine hydrochloride or 0.25% bupivacaine hydrochloride). More intense pain is best managed by removal of the band by hooked scissors or a hooked cutting probe (▶ Fig. 7.5). Most patients will require injection of local anesthetic in order to remove the band. Pain and swelling that develop several hours after banding may be due to edema and thrombosis distal to the banded area, which can usually be managed by conservative measures. Increasing rather than decreasing pain may require emergency evaluation by the surgeon.

Not infrequently, younger patients with high anal tone may experience mild to severe anismus. Also, fear of pain may cause patients to delay defecation as long as possible, leading to harder stools that are more difficult to pass. For these reasons, patients should be carefully counseled as to what to expect after banding. Fecal impaction is best avoided by limiting narcotic use, adding stool softeners, and maintaining adequate hydration.

Secondary thrombosis of external hemorrhoids may occur in 2 to 11% of patients. ³⁵ As with spontaneous thrombosis, mild symptoms can be treated with topical preparations and sitz baths. More severe complaints may require excision. Urinary retention is not common with rubber band ligation. When it does occur, onset is shortly after banding and will often resolve spontaneously, or may require one time catheterization. The development of difficult urination or urinary retention days after the procedure may herald pelvic sepsis, as described below.

Delayed hemorrhage may also occur, usually 7 to 10 days postprocedure as the banded tissue sloughs. Patients should be cautioned that they may notice a small amount of bleeding, which usually requires no treatment. Major bleeding is fortunately very rare, 0.5% out of 600 patients reviewed by Rothberg et al and others. ^{35 , 36} Significant bleeding demands immediate attention and may require suture ligation in the operating room. To minimize the risk of hemorrhage after banding, some providers ask their patients to refrain from any aspirin products before and after banding. However, little prospective data are available on the risks associated with aspirin use and postbanding hemorrhage. The experience with other anticoagulants such as warfarin is even less. With the increasing use of and need for anticoagulants, individual decisions must be made on the risks of stopping the anticoagulant and potential thrombosis compared to the risk of bleeding while remaining on the medication. The author currently bands patients on anticoagulation and has not seen significant postbanding bleeding.

The most serious complication is postbanding sepsis, believed to be related to necrosis from the banded tissue allowing adjacent soft tissue to become infected. ² First reported in 1980, it is associated with fever, perineal or pelvic pain, or both, and difficulty urinating. ^{37 , 38} Development of these symptoms after banding mandates urgent evaluation. A pelvic computed tomography (CT) scan will often demonstrate changes compatible with pelvic sepsis. Some patients may require an anesthetic to adequately evaluate the perineum. Large doses of broad-spectrum antibiotics to include clostridial coverage are indicated for empirical treatment to reduce the risk of potentially fatal sepsis. Operative debridement (drainage of any abscess and excision of necrotic tissue) and removal of the bands is reasonable, and in cases of overwhelming infections, a diverting colostomy may also be required. ²⁵

Success rates of rubber band ligation vary depending on the grade of hemorrhoids treated, length of follow-up, and the criteria for success. The results with rubber band ligation have been excellent with patient satisfaction of 80 to 91% in large series, but probably only 60 to 70% of patients have been completely cured of symptoms by one treatment session. ^{39 , 40 , 41} Recurrence at 4 to 5 years of follow-up is as high as 68% but symptoms usually respond to repeat ligations; only 10% of such patients require excisional hemorrhoidectomy. ⁴² If two or three banding sessions do not ameliorate the symptoms, an alternative form of therapy (e.g., hemorrhoidectomy) should be contemplated.

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6 Ambulatory and Anorectal Procedures 12 Condyloma Acuminatum 11 Perianal Dermatologic Disease Part II Anorectal Disease 16 Retrorectal Tumors 15 Rectovaginal and Rectourethral Fistulas

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