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Hemorrhoids

ANNE L. MOUNSEY, MD; JACQUELINE HALLADAY, MD, MPH; and TIMOTHY S. SADIQ, MD
University of North Carolina School of Medicine, Chapel Hill, North Carolina

Most patients with hemorrhoids experience only mild symptoms that can be treated with nonprescription topical
preparations. Patients usually seek treatment when symptoms increase. Internal hemorrhoids typically present with
prolapse or painless rectal bleeding. External hemorrhoids also bleed and can cause acute pain if thrombosed. Medi-
cal therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms. If medical
therapy is inadequate, surgical intervention is warranted. Rubber band ligation is the treatment of choice for grades
1 and 2 hemorrhoids. Rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be per-
formed in patients with grade 3 hemorrhoids. Rubber band ligation causes less postoperative pain and fewer complica-
tions than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate. Excisional
hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids. Stapled hem-
orrhoidopexy has a faster postoperative recovery, but a higher recurrence rate. Postoperative pain from excisional
hemorrhoidectomy can be treated with nonsteroidal anti-inammatory drugs, narcotics, ber supplements, and topi-
cal antispasmodics. Thrombosed external hemorrhoids can be treated conservatively or excised. (Am Fam Physician.
2011;84(2):204-210. Copyright 2011 American Academy of Family Physicians.)

Patient information: emorrrhoids result from dila- contribute to dilatation, engorgement, and
A handout on hemor- tion of the submucosal vas- prolapse of hemorrhoidal vascular tissue.
rhoids, written by the
authors of this article, is
cular tissue in the distal anal
provided on page 215. canal. This vascular tissue is Clinical Features
supported by connective tissue that, when Many persons treat the symptoms of hem-
weakened, leads to descent or prolapse of orrhoids without medical advice. Patients
the hemorrhoids. Internal hemorrhoids may present to physicians when symptoms
originate above the dentate line (i.e., the worsen. Both internal and external hemor-
junction between columnar and squamous rhoids can cause anal discharge and itching
epithelium) and are viscerally innervated because of difculty with hygiene. Internal
and, therefore, painless. External hemor- hemorrhoids typically cause prolapse or
rhoids originate below the dentate line, have painless rectal bleeding that is reported as
somatic innervation, and can cause pain. blood on the toilet paper or bleeding associ-
Some patients have both internal and exter- ated with bowel movements. External hem-
nal (mixed) hemorrhoids. orrhoids can cause anal discomfort because
Internal hemorrhoids are classied of engorgement. Thrombosis of external
according to their degree of prolapse. Grade 1 hemorrhoids can cause acute pain.
hemorrhoids may bleed but do not protrude;
DIAGNOSIS
grade 2 hemorrhoids protrude with defeca-
tion but reduce spontaneously; grade 3 hem- Several anorectal conditions may cause
orrhoids protrude and must be reduced by symptoms similar to those associated with
hand; and grade 4 hemorrhoids are perma- hemorrhoids (Table 1). Factors that may indi-
nently prolapsed.1 cate more serious conditions (e.g., cancer,
inammatory bowel disease) and that should
Epidemiology prompt consideration of colonoscopy include
The prevalence of hemorrhoids has been change in bowel habit, abdominal pain,
estimated at 4.4 percent of U.S. adults, with weight loss, rectal bleeding with blood in the
the highest prevalence in those between 45 stool, or a family history of colon cancer.
and 65 years of age.2 Factors that increase Physical examination should include an
intra-abdominal pressure (e.g., prolonged abdominal examination, inspection of the
straining, constipation, pregnancy, ascites) perineum, digital rectal examination, and
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Hemorrhoids
SORT: KEY RECOMMENDATIONS FOR PRACTICE

Evidence
Clinical recommendation rating References

Fiber supplementation should be recommended to decrease A 5


symptoms in all patients with hemorrhoids.
Excision of thrombosed external hemorrhoids provides more rapid B 8
pain relief than conservative treatment.
Rubber band ligation causes less postoperative pain and fewer A 11
complications than stapled hemorrhoidopexy and excisional
hemorrhoidectomy, and is the surgical treatment of choice for
grades 1 and 2 hemorrhoids.
Excisional hemorrhoidectomy has a lower risk of recurrence than A 10, 25, 26, 28
stapled hemorrhoidopexy.
Stapled hemorrhoidopexy causes less postoperative pain, pruritus, A 10, 25, 26, 28
and fecal urgency than excisional hemorrhoidectomy.
Topical diltiazem (obtained from a compounding pharmacy) B 30
can be used to decrease postoperative pain after excisional
hemorrhoidectomy.

A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evi-


dence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information
about the SORT evidence rating system, go to http://www.aafp.org/afpsort.xml.

anoscopy. Digital rectal examination alone Some experts recommend colonoscopy for
can neither diagnose nor exclude internal all patients older than 40 years who have
hemorrhoids; anoscopy is required. On anos- hemorrhoidal symptoms and rectal bleed-
copy, internal hemorrhoids appear as dilated ing.3 The American Society of Colon and
purplish-blue veins, and prolapsed internal Rectal Surgeons recommends taking the
hemorrhoids appear as dark pink, glistening, patient history and performing a physical
and sometimes tender masses at the anal mar- examination with anoscopy and further
gin (Figure 1). External hemorrhoids appear endoscopic evaluation if there is concern
less pink and, if thrombosed, are acutely ten- for inammatory bowel disease or cancer.4
der with a purplish hue (Figure 2). Perianal A complete evaluation of the colon is war-
skin tags, which are often remnants of previ- ranted in the following groups:
ous external hemorrhoids, may be present. Patients who are 50 years or older and

Table 1. Differential Diagnosis of Hemorrhoids

Diagnosis Historical features Physical examination ndings

Anal cancer Pain around anus; weight loss in Ulcerating lesion of anus
advanced cases
Anal condylomata Anal mass without bleeding; history Cauliower-like lesions
of anal intercourse
Anal ssure Tearing pain and bleeding with Painful rectal examination with ssure
bowel movement
Colorectal cancer Blood in stool, weight loss, Abdominal mass or tenderness
abdominal pain, change in bowel
habit, family history
Inammatory Constitutional symptoms, abdominal Normal external rectal examination;
bowel disease pain, diarrhea, family history rarely, stula; colitis on anoscopy
Perianal abscess Gradual onset of pain Tender mass covered with skin as
opposed to rectal mucosa
Skin tags No bleeding; history of resolved Tags visualized around anus covered
hemorrhoids with normal skin, not mucosa

July 15, 2011 Volume 84, Number 2 www.aafp.org/afp American Family Physician 205
Hemorrhoids

Figure 1. Grade 4 internal hemorrhoids. Figure 2. Thrombosed external hemorrhoid.

have not had a complete examination of the used for prolonged periods because of their
colon within the past 10 years atrophic effects on skin. Sitz baths are com-
Patients who are 40 years or older and monly recommended, but a review of studies
have not had a complete examination of the found no benet for various anorectal disor-
colon within the past 10 years, and who have ders, including hemorrhoids.6
one rst-degree relative in whom colorectal
THROMBOSED EXTERNAL HEMORRHOIDS
cancer or adenoma was diagnosed at age 60
years or younger Thrombosed external hemorrhoids cause
Patients who are 40 years or older and acute, severe pain. Without intervention, the
have not had a complete examination of the pain typically improves over two to three
colon within the past ve years, and who days, with continued improvement as the
have more than one rst-degree relative in thrombus gradually absorbs over several
whom colorectal cancer or adenoma was weeks. Analgesics and stool softeners may
diagnosed at age 60 years or younger be benecial. Topical therapy with nifedip-
Patients with iron deciency anemia ine and lidocaine cream (not available in the
Patients who have a positive fecal occult United States) is more effective for pain relief
blood test.4 than lidocaine (Xylocaine) alone.7
In patients with severe pain from throm-
Management bosed hemorrhoids, excision or incision and
MEDICAL TREATMENT evacuation of the thrombus within 72 hours
Medical management is appropriate for grade of symptom onset provide more rapid pain
1 hemorrhoids. All patients with hemorrhoids relief than conservative treatment.8 Both
should maintain soft bulky stools that can be procedures can be performed under local
passed without straining. This is also impor- anesthesia, and the resulting wound can be
tant after surgery because straining and pas- left open or sutured.9
sage of hard stools increase pain and bleeding,
and delay healing. Adequate intake of uid HEMORRHOIDS IN PREGNANCY
and ber helps soften the stool. A meta- Pregnancy predisposes women to symptom-
analysis of seven randomized trials of patients atic hemorrhoids that usually resolve after
with symptomatic hemorrhoids showed that delivery. Surgical intervention is contraindi-
ber supplementation with psyllium, stercu- cated because of the risk of inducing labor.
lia, or unprocessed bran decreased bleeding, Conservative treatment is recommended,
pain, prolapse, and itching.5 with excision of thrombosed external hem-
Nonprescription topical preparations con- orrhoids if necessary.
taining steroids, anesthetics, astringents,
and/or antiseptics are often recommended Surgical Treatment of Internal
for all grades of hemorrhoidal disease. How- Hemorrhoids
ever, no randomized studies support their Most patients with grade 1 or 2 hemorrhoids,
use. Steroid-containing creams should not be and many with grade 3 hemorrhoids, can be

206 American Family Physician www.aafp.org/afp Volume 84, Number 2 July 15, 2011
Hemorrhoids

treated in primary care ofces. Patients in as symptom relief for months to years, range
whom ofce-based treatment is ineffective from 70.5 to 97 percent.12-15
and those with mixed hemorrhoids may Complications such as vasovagal response,
require treatment in surgical suites with pain, abscess formation, urinary retention,
facilities for anesthesia. The most common bleeding, band slippage, and sepsis occur
surgical treatments are ligation or tissue in less than 2 percent of patients undergo-
destruction, xation techniques (i.e., hem- ing rubber band ligation.16-18 Secondary
orrhoidopexy), and excision (i.e., hemor- thrombosis of the external hemorrhoidal
rhoidectomy; Table 2). component may occur in 2 to 11 percent of
patients.19 Because of the risk of postoperative
RUBBER BAND LIGATION hemorrhage, rubber band ligation should not
Rubber band ligation is a common ofce be performed in patients receiving warfarin
treatment for internal hemorrhoids and is (Coumadin). Aspirin and other antiplatelet
often recommended as the initial surgical agents should be discontinued ve to seven
treatment for grades 1 to 3 hemorrhoids.10 days before the procedure and restarted ve
The procedure involves placing a rubber to seven days afterward.
band around a portion of redundant ano-
INFRARED COAGULATION
rectal mucosa. This causes strangulation of
the blood supply to the hemorrhoid, result- Infrared coagulation involves the applica-
ing in tissue necrosis and sloughing of the tion by a polymer probe tip of radiation
hemorrhoid in ve to seven days. Healing from a tungsten-halogen lamp to the base of
of the small residual ulcer provides xation the hemorrhoid. This creates an ulcer that
of the local mucosa to underlying muscle. subsequently heals, producing cicatrisation
The procedure is performed through an (scarring) that reduces blood ow to the
anoscope, and a variety of devices are avail- hemorrhoid. The procedure is well tolerated,
able to apply the bands. Because the bands but success rates are lower than those with
are placed in the insensate region (above rubber band ligation.13 Infrared coagulation
the dentate line), the procedure can be per- may be considered in patients who are on
formed without anesthesia. Nevertheless, anticoagulant therapy.20
the area should be tested for sensation before
EXCISIONAL HEMORRHOIDECTOMY
applying the band because of anatomic vari-
ation in innervation. One to three bands can In excisional hemorrhoidectomy, an ellipti-
be applied per session, depending on the cal incision is made over the hemorrhoidal
surgeons preference and patient tolerance. complex, which is then mobilized from
Subsequent bandings can occur at four- to the underlying sphincter and excised. The
six-week intervals.11 Rates of success, dened wound is closed with sutures.20

Table 2. Surgical Procedures for Internal Hemorrhoids

Type of surgery Procedure Anesthesia Comments

Excision Excisional Local with sedation Hospital based; preoperative enema needed
hemorrhoidectomy or general
Fixation Stapled Local with sedation Hospital based; preoperative enema needed
hemorrhoidopexy or general
Ligation and tissue Rubber band ligation None Ofce based; no preoperative enema needed
destruction Infrared coagulation None Ofce based; no preoperative enema needed
Injection sclerotherapy None Ofce based; no preoperative enema needed; higher
failure rate than rubber band ligation, excisional
hemorrhoidectomy, and stapled hemorrhoidopexy

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Hemorrhoids
Table 3. Comparison of Stapled Hemorrhoidopexy and Excisional
Hemorrhoidectomy

Favors excisional Favors stapled


Outcome measure (trials included in assessment) hemorrhoidectomy hemorrhoidopexy

Long-term risk of hemorrhoid recurrence at all time X


points (n = 7)*
Postoperative anal stenosis at all time points (n = 2) X
Postoperative bleeding at all time points (n = 6) X
Postoperative fecal urgency at nal follow-up (n = 4) X
Postoperative pain at all time points (n = 5) X
Postoperative pruritus at all time points (n = 2) X
Postoperative soiling or difculty with hygiene (n = 5) X
Postoperative symptom recurrence at nal follow-up X
(n = 5)

*Statistically signicant difference (P < .05).


Data suggest improved outcomes, but do not reach statistical signicance.
Information from reference 25.

Several randomized controlled trials STAPLED HEMORRHOIDOPEXY


(RCTs) and meta-analyses have shown that Stapled hemorrhoidopexy is an alternative
excisional hemorrhoidectomy is the most treatment for grades 2 to 4 hemorrhoids.23
effective treatment to reduce recurrent symp- The device removes a circumferential col-
toms in patients with grade 3 or 4 hemor- umn of mucosa and submucosa immediately
rhoids.3,21 It is also recommended for patients above the hemorrhoids, thus interrupt-
with mixed hemorrhoids and for those with ing the blood supply. The ring of staples
recurrent hemorrhoids in whom other treat- xes the downwardly displaced vascular
ments have been ineffective.21,22 cushions back into their original locations
A Cochrane review of three RCTs compar- to restore anatomy and function.24 Post-
ing excisional hemorrhoidectomy to rubber operatively, patients have a circular staple
band ligation showed that ligation resulted in line above the dentate line, which becomes
less postoperative pain and allowed patients buried within the mucosa over time. Staples
to return to work and to their previous level of can be noted within the rectum for many
functioning faster.11 Patients who underwent months after the procedure and can cause
excisional hemorrhoidectomy for grade 3 rectal bleeding.
hemorrhoids had less symptom recurrence Compared with excisional hemorrhoid-
and reduced need for subsequent procedures ectomy, stapled hemorrhoidopexy is more
compared with those who underwent rubber favorable in terms of postoperative pain,
band ligation. For patients with grade 2 hem- time until return to work, and complica-
orrhoids, there was no difference in symp- tions of pruritus and fecal urgency. How-
tom recurrence between the procedures. The ever, it is associated with higher long-term
authors concluded that rubber band ligation risk of recurrent hemorrhoids and the need
can be considered the treatment of choice for for additional procedures (Table 3).25 A
grade 2 hemorrhoids, reserving excisional meta-analysis of RCTs comparing long-term
hemorrhoidectomy for grade 3 hemorrhoids results (12 to 84 months) of both procedures
or recurrence after rubber band ligation. found that patients were twice as likely to
There was no difference between the proce- require further treatment after stapled hem-
dures in patient satisfaction or in the inci- orrhoidopexy.26 Short- and long-term data
dence of postoperative complications, such show similar patient satisfaction between the
as urinary retention, anal stenosis, or hemor- procedures, suggesting that the early postop-
rhage. Other postoperative complications of erative benets of stapled hemorrhoidopexy
excisional hemorrhoidectomy include skin may override the increased risk of additional
tags, abscess, stula, and anal leakage.20 surgery.26,27

208 American Family Physician www.aafp.org/afp Volume 84, Number 2 July 15, 2011
Hemorrhoids
Table 4. Surgical Treatment by Hemorrhoid Type

Hemorrhoid type/grade Ofce-based procedures Hospital-based procedures

External (not graded) In patients with severe symptoms, excision or


incision under local anesthesia within 72 hours
of onset; after 72 hours use medical treatment
Combined external Excisional hemorrhoidectomy
and internal
Internal grade 1 Rubber band ligation, infrared coagulation Rubber band ligation; excisional hemorrhoidectomy
if primary treatment is ineffective
Internal grade 2 Rubber band ligation, infrared coagulation Rubber band ligation; stapled hemorrhoidopexy;
excisional hemorrhoidectomy if primary
treatment is ineffective
Internal grade 3 Rubber band ligation Rubber band ligation; excisional
hemorrhoidectomy; stapled hemorrhoidopexy
Internal grade 4 Excisional hemorrhoidectomy; stapled
hemorrhoidopexy

OTHER PROCEDURES the surgeon. Rubber band ligation is usually


Cryotherapy, sclerotherapy, and anal dilata- the procedure of choice for grades 1 and 2
tion are less effective than hemorrhoidectomy hemorrhoids. In patients with circumferen-
or rubber band ligation.10,12,28 Sclerotherapy tial grade 2 disease, stapled hemorrhoidopexy
is sometimes used to treat grades 1 and 2 is associated with a lower recurrence rate but
hemorrhoids because it can be performed a longer time until return to work, and more
rapidly; however, it is not widely used. postoperative pain.23 Rubber band ligation
can be used for grade 3 hemorrhoids; stapled
POSTOPERATIVE CARE
hemorrhoidopexy and excisional hemor-
Excisional hemorrhoidectomy causes sig- rhoidectomy are also options and have better
nicant postoperative pain, whereas rubber long-term effectiveness, but cause more post-
band ligation and stapled hemorrhoidopexy operative pain and complications and have
typically are not painful. The use of non- longer recovery times. Excisional hemor-
steroidal anti-inammatory drugs, supple- rhoidectomy and stapled hemorrhoidopexy
mented with narcotics, is usually necessary. are options for grade 4 hemorrhoids. Exci-
However, narcotics can cause constipation, sional hemorrhoidectomy is recommended
leading to increased bleeding, pain, suture for mixed internal and external hemorrhoids,
breakdown, and loose staples. Stool softeners but infrared coagulation is a good option for
and bulking agents are recommended after patients who are on anticoagulation therapy
all procedures. Sitz baths and warm water (Table 4).
sprays can be used to keep the site clean, par- Data Sources: The following evidence-based medicine
ticularly after excisional hemorrhoidectomy. resources were searched using the key words stapled
Topical metronidazole (Metrogel) 10% hemorrhoidopexy, hemorrhoidectomy, hemorrhoids, hem-
orrhoid treatment, rubber band ligation hemorrhoids, hem-
applied three times per day and topical dil-
orrhoid surgery, hemorrhoids pregnancy, and thrombosed
tiazem have been shown to decrease postop- external hemorrhoids: Essential Evidence Plus, the Cochrane
erative pain29,30 ; these formulations are not Database of Systematic Reviews, Pubmed, UpToDate, the
available commercially but can be obtained National Guideline Clearinghouse, the Institute for Clinical
Systems Improvement, and the Database of Abstracts of
from a compounding pharmacy. Topical Reviews of Effects. Search date: January 12, 2010.
nitroglycerin 0.2% applied twice per day
decreases postoperative pain by relaxation of The Authors
spasm in the internal anal sphincter.31
ANNE L. MOUNSEY, MD, is an associate professor of family
medicine in the Department of Family Medicine at the Uni-
Choice of Procedure versity of North Carolina School of Medicine, Chapel Hill.
The choice of procedure should be based JACQUELINE HALLADAY, MD, MPH, is a research assistant
on the patients symptoms, the extent of the professor of family medicine at the University of North
hemorrhoidal disease, and the experience of Carolina School of Medicine.

July 15, 2011 Volume 84, Number 2 www.aafp.org/afp American Family Physician 209
Hemorrhoids

TIMOTHY S. SADIQ, MD, is an assistant professor of sur- 15. Komborozos VA, Skrekas GJ, Pissiotis CA. Rubber band
gery at the University of North Carolina School of Medicine. ligation of symptomatic internal hemorrhoids: results of
500 cases. Dig Surg. 2000;17(1):71-76.
Address correspondence to Anne L. Mounsey, MD, 16. Sardinha TC, Corman ML. Hemorrhoids. Surg Clin North
University of North Carolina School of Medicine, 590 Am. 2002;82(6):1153-1167.
Manning Dr., Chapel Hill, NC 27514 (e-mail: anne_
17. Bat L, Melzer E, Koler M, Dreznick Z, Shemesh E. Compli-
mounsey@med.unc.edu). Reprints are not available cations of rubber band ligation of symptomatic internal
from the authors. hemorrhoids. Dis Colon Rectum. 1993;36(3):287-290.
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disclose. sepsis following treatment for haemorrhoids: a system-
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19. Beck DE. Hemorrhoidal disease. In: Beck DE, Wexner
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210 American Family Physician www.aafp.org/afp Volume 84, Number 2 July 15, 2011