Hemorrhoids are a common problem seen in the primary care and
ambulatory surgery setting. Hemorrhoids are actually vascular cushions
located within the anal canal. They occur in three constant positions:
Right Anterior, Right Posterior, and Left Lateral. Hemorrhoids can be
internal (originating above the dentate line), external (originating below the
dentate line), or mixed. Internal hemorrhoids (also known as "piles") are
caused by prolapses of rectal mucosa containing the normally dilated veins of
the internal venous plexus. External hemorrhoids are thromboses in the
veins of the external rectal venous plexus, and as such are covered by skin.
The major precipitator of hemorrhoids is increased rectal
pressure (most often due to straining or constipation). Other causes of
increased pelvic pressure such as pregnancy, portal hypertension, and excessive
diarrhea can exacerbate their development as well.
Because of the differing nervous innervation above and below
this line, the clinical presentation will differ as well.
The classic presentation of a patient with hemorrhoids is
bleeding (typically with defecation). The bleeding associated with
hemorrhoids coats the stool or toilet paper (bright red), whereas the stool is
negative for occult blood. Most cases of hemorrhoids are painless, unless there is subsequent
thrombosis or ulceration. In fact, although patients may complain of
burning or itching, the fact is that hemorrhoids, themselves, do not itch or
burn. It is the perianal skin which is the site of pruritis, and is
typically the result of poor hygiene in that area (perhaps secondary to pain
Internal hemorrhoids can be classified into 4
There is no classification for external hemorrhoids.
Treatment of hemorrhoids is
based on the severity of symptoms and degree of disease (as above).
For asymptomatic disease, conservative management will usually suffice.
Bulk-forming agents, the avoidance of constipation, and sitz baths will
typically eradicate the problem, or lessen symptoms. Accordingly,
first degree, asymptomatic hemorrhoids are treated in this manner.
With symptomatic disease, rubber-band ligation or infrared coagulation may
be tried. Sclerotherapy (an older therapy), has largely been
abandoned. In the banding procedure, a small rubber-band is
placed around the base of the hemorrhoid, causing the tissue to die and fall
off as a result of lack of blood flow. Likewise, this banding
procedure is helpful for second and third degree hemorrhoids as well.
Surgery (in the form of hemorrhoidectomy) is typically reserved for fourth
degree hemorrhoids (or some mixed third degree's with a large external
component). In these instances, the large vein is removed and gauze
packing is inserted to control bleeding. The outcome following surgery
is very good in the majority of cases, and the patient should be encouraged
to adhere to a high fiber diet and avoid constipation in order to avoid
recurrence. In terms of convalescence, patients may experience
considerable pain after surgery as the anus tightens and relaxes, but
complete recovery is usually seen within two weeks.
hemorrhoids typically do not cause many problems. Excision is
typically reserved for very large hemorrhoids which interfere with good
perianal hygiene. Occasionally, patients may present with severe
perianal pain and a lump near the anus following severe constipation or
prolonged sitting. Visual or rectal exam may reveal a thrombosed
external hemorrhoid. A thrombosed external hemorrhoid is one in which
blood has pooled and formed a clot. This type of hemorrhoid occurs outside
the rectum, around the anal region. It will usually appear as bulging,
purple or bluish skin-covered veins, or can be reddish when inflamed. To the
touch, it usually feels like a small, hard lump, roughly the size of a pea.
With this type of hemorrhoid, most sufferers experience some degree of pain,
often quite a lot. A thrombosed external hemorrhoid can cause swelling,
itching and/or pain, but it will almost never bleed. The usual treatment is
drainage or removal of the clot or the entire hemorrhoid, but only if the
condition is acute (<72 hours). Otherwise, expectant management and a
high fiber diet is typically all that is needed, as the problem is usually
self-limited over 7-10 days.