Dayton Colon & Rectal Center

Hemorrhoids

I. Statement of the Problem

Hemorrhoids are normal components of human anatomy. External hemorrhoids arise from the inferior hemorrhoidal plexus and are covered by modified squamous ephithelium distal to the dentate line. They can swell or become thrombosed causing pain or they may ulcerate with subsequent bleeding. The thrombosis can ultimately resolve or a skin tag may remain with the possibility of itching, burning, and soilage.

Internal hemorrhoids are classified as first-degree, second-degree, third-degree, and fourth-degree.

First-degree hemorrhoids arise in the submucosal vascular tissue above the dentate line. These increase in number and size and may bleed with defecation. They project into the lumen and are seen with an anoscope, but do not prolapse.

Second-degree internal hemorrhoids protrude on defecation but return spontaneously with cessation of straining. They may bulge into the lumen on anoscopy.

Third-degree hemorrhoids protrude with straining and can be seen on physical exam outside the anal verage. Persistent or intermittent manual reduction is necessary.

Fourth-degree hemorrhoids are irreducibly prolapsed. They may be thrombosed.

Internal hemorrhoids originate from the superior hemorrhoidal plexus and are covered by mucosa proximal to the dentate line. Symptomatic internal hemorrhoids may cause: bleeding, protrusion, swelling, mucous discharge, soiling, burning, itching, and pain.

II. Decision to Treat Symptomatic External and Internal Hemorrhoids

The approach to treatment depends on the patient's symptoms. Hemorrhoidal symptoms may be a manifestation of a myriad of medical conditions and therefore careful evaluation of the patient must be conducted to try to determine underlying causes of the patient's complaints. A history includes assessment of the patient's coagulation history, the possibility of immunosuppressive disease, and the need for antibiotic prophylaxis. If possible, before initiating any therapy, rectosigmoid evaluation and anoscopy should be performed.

A. MEDICAL TREATMENT

Symptomatic external and internal hemorrhoids can be treated medically if symptoms are secondary to suspected alterations in diet, stool consistency (diarrhea or constipation) or poor hygiene. Medical treatment is reserved for minor symptoms which do not prevent required daily activities. Medical treatment may include the application of warm sitz baths, correction of diet, stool modifiers, and the use of topical creams. Prolonged use of topical steroids is potentially harmful.

B. SURGICAL THERAPY

Patients with acute hemorrhoidal disease or crisis may seek attention because of pain, hemorrhage, or debilitation. Secondary surgical opinion is likely to cause the patient undue delay in treatment, therefore, second surgical opinion should not be required to begin treatment in patients with hemorrhage, acute thrombosed external or internal hemorrhoids, or acute hemorrhoidal disease superimposed on a chronic problem.

External Hemorrhoids

Surgical removal of external hemorrhoids is indicated if symptoms require emergency intervention or if medical treatment has failed and chronic symptoms persist. External hemorrhoidectomy can be performed as an outpatient procedure.

Internal Hemorrhoids

Surgery is indicated in chronic internal hemorrhoidal disease in the following cases:

Patients who fail more conservative measures of treatment. These include rubber band ligation, dilatation, infrared coagulation, laser surgery, and bipolar diathermy coagulation.
Patients who have symptomatic hemorrhoidal disease associated with other benign anorectal conditions which require surgery. These include patients with fistula, fissure, hypertrophied, papilla, or stenosis.
Patients who request initial operative hemorrhoidectomy instead of alternative therapy after consultation with the surgeon.
Patients who have had third and fourth-degree hemorrhoids, with or without external components, and who have severe symptoms and signs from their hemorrhoidal disease, may be treated by elective surgery.

Following surgical treatment of internal hemorrhoids, with or without external hemorrhoids, ambulatory or inpatient stay is judged by the operating surgeon based on the findings at surgery and the clinical condition of the patient.

C. ALTERNATIVE THERAPIES

Acute or chronic hemorrhoidal symptoms secondary to internal hemorrhoids can be treated with alternative therapies:

Injections. Traditionally indicated for first and second-degree hemorrhoids but not for use with external hemorrhoids.

Rubber Bands. Rubber banding or elastic band ligation may be indicated for the treatment of symptoms with first and second-degree hemorrhoids. These treatments remain in many controlled trials, the treatment of choice for first and second- degree hemorrhoids that are complicated with symptoms of bleeding and/or prolapse. The literature supports either single or multiple bands in a single treatment and the band site may or may not be injected.

Cryotherapy. Cryotherapy is most effective with the least side effects when directed at first and second-degree hemorrhoids. It is not recommended for use with external hemorrhoids. We have not had good results with cryotherapy.

Infrared. Controlled trials indicate that it is useful for first and second degree hemorrhoids, however first and second-degree hemorrhoids may need multiple treatments and alternative methods may be more efficacious (i.e., rubber band ligations).

Dilatation. Not preferred as an alternative treatment for internal hemorrhoids due to lack of controlled trials, unfamiliarity of the technique in the United States, and significant risk of incontinence in published reports.

Laser. Laser advocates suggest that a critical advantage of the use of laser energy is precise control over the depth of destruction. They say this translates into minimized associated tissue injury which in turn results in less scarring, more rapid healing, and possibly less pain for the patient. After extensive work and reports, laser treatment of hemorrhoids has not resulted in lower pain or bleeding for the patient; therefore, we have stopped using the laser routinely.

Bipolar Diathermy Coagulation. Alternative procedure for fixation. Significant clinical data not yet available.

III. Outcome

Following treatment, attention, and proper instructions should be given in regard to pain control, bowel movements, voiding patterns, and wound care in an effort to minimize complications associated with therapy. The necessity and timing for adequate follow up exams is in the judgement of the physician. Persistent heavy bleeding or delayed hemorrhage should be evaluated promptly. Postoperative sepsis is usually heralded by intractable pain, fever, and urinary retention. Patients demonstrating these symptoms should be seen as soon as possible by the physician.