Hemorrhoids are dilated vessels of the hemorrhoidal plexus in the anal canal. Symptoms include irritation and bleeding. Thrombosed hemorrhoids are usually painful. Diagnosis is by inspection or anoscopy. Treatment is symptomatic or with rubber banding, injection sclerotherapy, infrared photocoagulation, or sometimes surgery.
(See also Evaluation of Anorectal Disorders.)
Increased pressure in the veins of the anorectal area leads to hemorrhoids. This pressure may result from pregnancy, frequent heavy lifting, or repeated straining during defecation (eg, due to constipation). Hemorrhoids may be external or internal. In a few people, rectal varices result from increased blood pressure in the portal vein, and these are distinct from hemorrhoids.
External hemorrhoids are located below the dentate line and are covered by squamous epithelium.
Internal hemorrhoids are located above the dentate line and are lined by rectal mucosa. Hemorrhoids typically occur in the right anterior, right posterior, and left lateral zones. They occur in adults and children.
Symptoms and Signs of Hemorrhoids
Hemorrhoids are often asymptomatic, or they may simply protrude. Pruritus ani is not commonly caused by hemorrhoids unless they are significantly prolapsed.
External hemorrhoids may become thrombosed, resulting in a painful, purplish swelling. Rarely, they ulcerate and cause minor bleeding. Cleansing the anal region may be difficult.
Internal hemorrhoids typically manifest with bleeding after defecation; blood is noted on toilet tissue and sometimes in the toilet bowl. Internal hemorrhoids may be uncomfortable but are not as painful as thrombosed external hemorrhoids. Internal hemorrhoids sometimes cause mucus discharge and a sensation of incomplete evacuation.
Strangulated hemorrhoids occur when protrusion and constriction occlude the blood supply. They cause pain that is occasionally followed by necrosis and ulceration.
Diagnosis of Hemorrhoids
Anoscopy
Sometimes sigmoidoscopy or colonoscopy
Most painful hemorrhoids, thrombosed, ulcerated, or not, are seen on inspection of the anus and rectum.
Anoscopy is essential in evaluating painless or bleeding hemorrhoids. Rectal bleeding should be attributed to hemorrhoids only after more serious conditions are excluded (ie, by sigmoidoscopy or colonoscopy).
Internal hemorrhoids can be classified by grade according to certain features (see table Classification of Internal Hemorrhoids), which can help guide treatment.
Classification of Internal Hemorrhoids
Grade | Features |
|---|---|
I | Prominent hemorrhoids No prolapse |
II | Prolapse after a Valsalva maneuver Prolapse reduces spontaneously |
III | Prolapse after a Valsalva maneuver Prolapse needs manual reduction |
IV | Chronic prolapse Manual reduction of prolapse ineffective |
Adapted from the American Society of Colon and Rectal Surgeons’ 2018 clinical practice guidelines for the management of hemorrhoids. | |
Pearls & Pitfalls
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Treatment of Hemorrhoids
Symptomatic: Stool softeners, sitz baths, analgesics
Occasionally excision for thrombosed external hemorrhoids
Injection sclerotherapy, rubber band ligation, or infrared photocoagulation for internal hemorrhoids
(See also the American Society of Colon and Rectal Surgeons’ [ASCRS] 2018 clinical practice guidelines for the management of hemorrhoids.)
Symptomatic treatment
Office-based procedures
Patients with grades I and II internal hemorrhoids and some patients with grade III internal hemorrhoids (see table Classification of Internal Hemorrhoids) who do not respond to symptomatic treatment can often be treated effectively with the following office-based procedures (see also the ASCRS 2018 clinical practice guidelines).
Injection sclerotherapy
Rubber band ligation is used for larger, prolapsing internal hemorrhoids, bleeding internal hemorrhoids, or those that do not respond to conservative management. With mixed internal and external hemorrhoids, only the internal component should be rubber band–ligated. The internal hemorrhoid is grasped and withdrawn through a stretched ½-cm diameter band, which is released to ligate the hemorrhoid, resulting in its necrosis and sloughing. Typically, one hemorrhoid is ligated every 2 weeks; 3 to 6 treatments may be required. Sometimes, multiple hemorrhoids can be ligated at a single visit, but this may cause more pain. External hemorrhoids should not be banded.
Infrared photocoagulation is useful for ablating nonprolapsing, bleeding internal hemorrhoids, or hemorrhoids that are not cured with rubber band ligation.
Surgical hemorrhoidectomy
Surgical hemorrhoidectomy is required for patients who do not respond to other forms of therapy and for those who have grade IV internal hemorrhoids. Significant postoperative pain is common, as are urinary retention and constipation.
Stapled hemorrhoidopexy is an alternative procedure for circumferential hemorrhoids and causes less postoperative pain but has higher recurrence and complication rates than conventional surgical hemorrhoidectomy.
Other procedures
Doppler-guided hemorrhoid artery ligation, in which a rectal ultrasound probe is used to identify vessels for suture ligation, is promising but requires further study to determine its overall utility.
Laser destruction, cryotherapy, and various types of electrodestruction are of unproven efficacy.
Key Points
External hemorrhoids may thrombose and become very painful but rarely bleed.
Internal hemorrhoids often bleed but are not often painful.
Stool softeners, topical treatments, and analgesics are usually adequate treatment for external hemorrhoids.
Bleeding internal hemorrhoids may require injection sclerotherapy, rubber band ligation, or infrared photocoagulation.
Surgery is a last resort.
More Information
The following English-language resource may be useful. Please note that THE MANUAL is not responsible for the content of this resource.
American Society of Colon and Rectal Surgeons: Clinical practice guidelines for the management of hemorrhoids (2018)
