Treatment
Medical Therapy
Treatment is divided by the cause of symptoms, into internal and external treatments. Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic. They are classified by symptoms and are grouped into 4 stages, as described in the Staging section.
Because it is believed that straining and a low-fiber diet cause hemorrhoidal disease, conservative treatment includes increasing fiber and liquid intake and retraining in toilet habit.9 Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, first-line treatment of all first- and second-degree (and many third- and fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation.
Psyllium seed significantly decreases bleeding and pain compared with placebo. The average American diet consists of 8-15 grams of fiber per day. A high-fiber diet includes more than 25 grams of fiber per day. Psyllium seed (Metamucil) and methylcellulose (Citrucel) are the most commonly used supplements. Many hemorrhoidal symptoms resolve only when they are treated with dietary alterations, including increased fiber and the addition of fiber supplements.
Antidiarrheal agents are sometimes required in patients with symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids.
Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, also have a small role in the treatment of hemorrhoidal symptoms. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. The author rarely recommends typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. Submucosal veins do not get smaller with anti-inflammatory medications.
Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. The author does not suggest mechanisms such as the sitz bath for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role in the treatment of older or immobile patients who cannot routinely get in and out of a bathtub.
Many patients see improvement or complete resolution of their symptoms with the above conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after 1 month of conservative therapy. Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids.
Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. A wise professor once said, "You can't make an asymptomatic patient feel better." Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome.
Treatment of the underlying disease often relieves anal symptoms. Patients with ulcerative colitis can tolerate aggressive surgery if needed. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere.
Pregnancy is associated with many anorectal complaints. Treatment is directed at symptoms. Nonoperative treatment or office thrombectomy usually relieves complaints. Operative hemorrhoidectomy is safe in pregnant women.10
HIV and anal disease often occur together. Again, conservative therapy is suggested, especially if immunosuppression is evident. Poor healing occurs with low CD4 counts, especially those of less than 200 cells/mm3.
Numerous methods to destroy internal hemorrhoids are available; they include rubber band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, carbon dioxide freezing, Lord dilatation, stapled hemorrhoidectomy, and surgical resection.11,12,13 All of these methods (except stapled hemorrhoidectomy and surgical resection) are considered nonoperative treatments and should be the first-line treatment of all first- and second-degree internal hemorrhoids that do not respond to conservative therapy.
With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively. All nonoperative treatments have approximately similar efficiency when administered by an experienced clinician. Rubber band ligation is most common in the United States, because it is the most commonly taught method in training programs.14 Blaisdell and Barron described and refined ligation therapy.15,16 Lord dilatation is seldom used in the United States, and many colorectal surgeons condemn its use, because it is essentially an uncontrolled disruption of the sphincter mechanism.
Sclerotherapy can provide adequate treatment of early internal hemorrhoids.17,18 Cryotherapy and sclerotherapy are infrequently used today. Most experienced surgeons use 1 or 2 techniques exclusively.
Symptoms have historically been treated with dietary modifications, incantations, voodoo, quackery, and application of a hot poker. Molten lead has also been described as a treatment. The adverse effects of these treatments have a direct relationship to whether patients relay persistent or recurrent complaints to the clinician or return for further treatment.
Surgical Therapy
Operative resection is reserved for patients with third- and fourth-degree hemorrhoids, patients who fail nonoperative therapy, and patients who also have significant symptoms from external hemorrhoids or skin tags. Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, one prospective study found no difference between scalpel and laser hemorrhoidectomy.19 The reader is referred to appropriate textbooks to see descriptions of techniques used.20,21
External hemorrhoids generally elicit symptoms due to acute thromboses, recurrent thromboses, or hygiene problems. Manage acute thromboses and recurrent thromboses in a similar fashion. Identify the offending vascular cluster. In the office or clinical setting, inject local anesthetic, and then perform excision of the overlying skin and underlying veins.
Enucleation of the thrombosis alone can result in recurrence of the hemorrhoid at the same spot; excision of the underlying vein completely prevents this event. Electrocoagulation or topical astringent (Monsel's solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone.
Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), has become prominent.22,23,24 It was first described in 1997-1998. During PPH, a specially designed circular stapler with smaller staples is used. The technique involves placing a suture in the mucosal and submucosal layers circumferentially, approximately 3-4 cm above the dentate line. The stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a circular staple line above the dentate line. This results in resection of excessive internal hemorrhoidal tissue, pexy of the internal hemorrhoidal tissue left behind, and interruption of the blood supply from above. PPH can be done as an outpatient procedure, using local anesthesia with intravenous (IV) sedation.
PPH is mainly used to treat internal hemorrhoids that are not amenable to conservative and nonoperative therapies. Narcotic use and recovery is significantly decreased compared with conventional operative hemorrhoid surgery.
PPH does not directly affect the external tissue. Reports have described shrinking of external hemorrhoidal tissue after PPH, probably from decreased blood flow. Good results from PPH combined with judicial excision of occasional skin tags also have been reported.
In patients receiving PPH, pain seems to be less severe and of shorter duration than it is in patients who undergo conventional surgery. The use of PPH is suggested in patients with large internal hemorrhoids and minimal external component. This procedure can be done in an outpatient setting with local anesthesia, similar to the protocol used for conventional hemorrhoid surgery. The author has incorporated PPH into practice more frequently, with excellent results.
Operative resection is reserved for patients with hygiene trouble caused by large skin tags, a history of multiple external thromboses, or internal hemorrhoid trouble. Perform the operation in the outpatient setting. Proper anesthetic care (especially if local anesthesia with supplementary IV sedation), attention to perioperative fluid restriction, and careful postoperative instructions can ease the patient's recovery. Operative technique can be found in any colorectal surgical textbook.
Patients with ulcerative colitis can tolerate aggressive surgery if it is needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women.10
Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is large internal hemorrhoid prolapse. The sphincter mechanism squeezes, incarcerating the internal hemorrhoids and strangulating them. The resulting spasm causes edema and occasionally thrombosis of the external hemorrhoids. The resulting pain and swelling are dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported.
Preoperative Details
Hemorrhoid surgery can usually be performed using local anesthesia with IV sedation. Regional or general anesthetic techniques also are used. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas.
Intraoperative Details
The reader is referred to detailed surgical textbooks for specific details.20,21
Postoperative Details
Attention to regular and soft bowel movements is important. Bulk agents (eg, psyllium seed) and oral fluids are important. Bathing in tubs for comfort and hygiene is part of the routine. Judicious narcotic administration relieves pain.
Follow-up
Monitor patients at regular intervals until they are healed and have no symptoms.
Complications
Well-trained surgeons should experience complications in fewer than 5% of cases. Complications include stenosis, bleeding, infection, recurrence, nonhealing wounds, and fistula formation. Urinary retention is directly related to the anesthetic technique used and to the perioperative fluids administered. Limiting fluids and the routine use of local anesthesia can reduce urinary retention to less than 5%.
More on Hemorrhoids |
| Overview: Hemorrhoids |
| Workup: Hemorrhoids |
 Treatment: Hemorrhoids |
| Follow-up: Hemorrhoids |
| References |
| Further Reading |
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Further Reading
Related eMedicine topics:
Constipation [Emergency Medicine]
Constipation [Gastroenterology]
Constipation [Pediatrics: General Medicine]
Constipation and Bowel Management
Crohn Disease [Gastroenterology]
Crohn Disease [Pediatrics: General Medicine]
Crohn Disease [Radiology]
Hemorrhoids [Emergency Medicine]
Inflammatory Bowel Disease [Emergency Medicine]
Inflammatory Bowel Disease [Gastroenterology]
Inflammatory Bowel Disease [Ophthalmology]
Portal Hypertension [Gastroenterology]
Portal Hypertension [Radiology]
Rectal Prolapse [Emergency Medicine]
Rectal Prolapse [General Surgery]
Rectal Prolapse [Pediatrics: General Medicine]
Rectal Prolapse: Surgical Perspective
Thrombosed External Hemorrhoid Excision
Ulcerative Colitis [Gastroenterology]
Ulcerative Colitis [Pediatrics: General Medicine]
Ulcerative Colitis [Radiology]
Keywords
hemorrhoids, piles, hemorrhoid, external hemorrhoids, internal hemorrhoids, hemorrhoids treatment, external hemorrhoid, hemorrhoids surgery, hemorrhoidectomy, hemorrhoidal, hemorrhoids pregnancy, bleeding hemorrhoids, thrombosed hemorrhoids, hemorrhoids cure, hemorrhoids symptoms, hemorrhoids cause, hemorrhoids pain, internal hemorrhoid, inflammatory bowel disease, hemorrhoidal problems, anorectal problems, ulcerative colitis, Crohn disease, enlarged hemorrhoids, straining, constipation, anorectal varices, prolapsed internal hemorrhoids, rectal prolapse, perianal pain, pruritus ani
