For the most part, symptomatic hemorrhoids are a quality-of-life issue. All patients should initially receive conservative management If this fails to improve symptoms, an office-based or operative procedure may be offered. Office-based treatments include sclerotherapy, rubber-band ligation, and infrared coagulation, Operative treatments include excisional hemorrhoidectomy, stapled hemorrhoidopexy (procedure for prolapse and hemorrhoids [PPH]), and hemorrhoid artery ligation (HAL). (See Technique.)
Despite several years of study, the main etiology of hemorrhoidal disease is still largely unknown. Many theories have been proposed, but the most common, and perhaps most accurate, pertains to the abnormal sliding of the vascular cushions that is associated with straining and irregular bowel habits. Hard, bulky stools promote straining, which is more likely to push the cushions out of the anal canal. Furthermore, straining may cause engorgement of the cushions during defecation, making their displacement more likely. Congestion and hypertrophy of the anal cushions ensue, making them more prone to developing edema and bleeding. 
It is useful to classify hemorrhoids as external or internal (see Technical Considerations below).
Bleeding is the most common presenting symptom of hemorrhoidal disease. It usually manifests as bright red blood, recognized first on the toilet paper with defecation and later becoming heavier and noticed in the toilet. With time, bleeding may be unrelated to defecation. 
Prolapse of internal hemorrhoids is highly characteristic of more advanced and chronic hemorrhoidal disease. The prolapsed internal hemorrhoids may reduce spontaneously or may need to be reduced manually. In rare cases, they may prolapse through the anal canal and become incarcerated.
In the absence of thrombosis or incarceration, hemorrhoids are usually painless. Dull pain after defecation is common with prolapsed hemorrhoids and is relieved by reducing the prolapse. If someone is experiencing severe pain, a complication of hemorrhoids or another diagnosis, such as anal fissure, abscess, or rectal ulceration, must be considered. [3, 2]
Patients may experience mucoid anal discharge or fecal soilage as internal hemorrhoids prolapse through the anal canal. This irritation of the perianal skin can result in significant pruritus. 
Thrombosis is the most painful complication of internal or external hemorrhoids. The pain is often severe enough to affect routine daily activities. While it can occur in large, prolapsed hemorrhoids, thrombosis is more common in external hemorrhoids. If the epithelium overlying the thrombosed hemorrhoid breaks down and allows invasion of bacteria, it may lead to infection, which is rare. 
The incidence of hemorrhoidal bleeding that results in anemia is low.
Thrombosed external hemorrhoids diagnosed within 72 hours of symptom onset may undergo surgical excision with excellent results. Often, such excision can be done in the office setting; however, in the event of extensive hemorrhoids, the physician may prefer to perform the procedure in the operating room. Simple incision and drainage should be avoided because there is a high risk of reaccumulation, which may worsen symptoms. Overall, management should be based on the severity of the patient's symptoms at the time of diagnosis. [3, 4]
Failed medical management is the primary indication for surgery. The authors usually offer escalating treatments, from least invasive to most invasive. For bleeding hemorrhoids refractory to dietary modification, rubber-band ligation is their preferred treatment. Sclerotherapy and infrared coagulation are also options.
With prolapse of tissue, rubber-band ligation requires multiple applications; thus, the authors offer HAL or stapled hemorrhoidopexy (PPH). The authors prefer HAL in women, on the grounds that there is less dilation of the sphincter complex and no cutting of tissue. They believe that this provides a safe and effective treatment without posing a significant risk to the sphincter complex. With large prolapsing hemorrhoids, they offer PPH or excision. In patients with a large external component, excision is the most effective option.
Symptomatic hemorrhoidal disease affecting quality of life is the general indication for intervention. Symptoms include pain, bleeding, and difficulty with hygiene. In some cases of patients on antiplatelet or anticoagulation therapy or patients with hemophilia, surgical intervention is needed to prevent hemorrhage.
Contraindications are dependent on the specific symptoms and therefore the specific therapy being offered. Dietary modification is simple and effective, yet patients with irritable bowel syndrome may not tolerate a high-fiber lifestyle.
Patients with contraindications to anesthesia due to significant medical comorbidities should not be offered surgical therapy for hemorrhoids unless there is sepsis or significant hemorrhage with anemia. Often, these procedures can be performed with local anesthesia.
Relative contraindications include fecal incontinence, rectoceles, bleeding disorders, portal hypertension with rectal varices, and Crohn disease. Because hemorrhoids contribute to overall fecal continence, excision or removal may worsen a patient with borderline sphincter function. Women with rectoceles can develop obstructed defecation syndrome postoperatively if any stenosis occurs; use of a stapler is discouraged because of the risk of incorporating the vaginal mucosa in the staple line and causing a fistula. The authors prefer excision and closure in patients with bleeding disorders because direct suturing of the pedicles may reduce the risk of a postoperative bleed.
In patients with Crohn disease or portal hypertension with rectal varices, surgery should be reserved as a final option because morbidity is high in these patients. 
Anal vascular cushions are present in everyone and are believed to contribute, in small part, to overall anal continence. The term hemorrhoids is used to refer to these cushions when they become enlarged and symptomatic. 
These anal cushions are composed of plexuses of vessels within the anal canal that connect arterioles to veins without intervening capillaries. They are also normally supported by smooth muscle fibers (Treitz muscle) and connective tissues in the submucosa that help maintain their position in the upper half of the canal. Repeated stretching of these attachments causes disruption and results in prolapse.  Anatomically, these major vascular cushions are typically located in the following three main positions:
The anal canal is completely extraperitoneal. The length of the (surgical) anal canal is about 3-5 cm, with two thirds of this being above the dentate line and one third below the dentate line (anatomic anal canal). (See the image below.) For more information about the relevant anatomy, see Anal Canal Anatomy.
When hemorrhoids are symptomatic, smaller, secondary cushions may be present between the main cushions.
External hemorrhoids originate below the dentate line and are covered by squamous epithelium. They are in sensitive anal canal skin and are painful. Internal hemorrhoids are located above the dentate line and are covered by transitional or columnar epithelium.They are in insensitive anal canal mucosa and are painless (unless complicated).
Internal hemorrhoids can further be divided into four categories on the basis of the extent of prolapse, as follows:
Grade 1 - Hemorrhoids bulge into the lumen of the anal canal but do not descend below the dentate line.
Grade 2 - Hemorrhoids prolapse below the dentate line with straining but reduce spontaneously (see the first image below)
Grade 3 - Hemorrhoids prolapse with straining or defecation and have to be reduced manually (see the second and third images below)
Grade 4 - Hemorrhoids are permanently prolapsed and irreducible (see the fourth image below)
The early experience with stapled hemorrhoidopexy (also referred to as stapled hemorrhoidectomy, circumferential mucosectomy, or PPH) found it to be safe and effective. Because all the work is done above the dentate line, there is less pain than with conventional excision. Studies have shown significant reduction in postoperative pain, quicker recovery and earlier return to work, and a low incidence of complications (see the images below).
Long-term studies suggested that recurrence rates may be higher than with conventional hemorrhoidectomy; however, a 2015 study comparing long-term outcomes in closed hemorrhoidectomy versus stapled hemorrhoidopexy found that patient satisfaction, resolution of symptoms, quality of life, and functional outcome appeared to be similar. [5, 3, 2, 1, 6]
In a prospective, randomized trial that included 180 patients with hemorrhoids who were treated with open hemorrhoidectomy (n=60), semiclosed hemorrhoidectomy (n=60), or stapled rectal mucosectomy (ie, stapled hemorrhoidopexy; n=60), Ripetti et al found that patients in the second and third groups resumed work earlier, experienced less pain, and had fewer complications. 
Aytac et al assessed circular stapled hemorrhoidopexy (mean follow-up, 6.3±2.9 years) against Ferguson hemorrhoidectomy (mean follow-up, 7.7±3.4 years) with respect to long-term outcomes and quality of life in 217 patients who underwent surgical treatment of hemorrhoids.  They found the two approaches to be similar over the long term with regard to patient satisfaction, resolution of symptoms, quality of life, and functional outcome.
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