eMedicine Specialties > Clinical Procedures > Soft Tissue Procedures

Thrombosed External Hemorrhoid Excision

Brett Wallace Lorber, MD, MPH, Staff Physician, Emergency Department, Olive View/UCLA Medical Center
Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital

Updated: Apr 30, 2009

Introduction

External hemorrhoids occur distal to the dentate line and develop as a result of distention and swelling of the external hemorrhoidal venous system. Engorgement of a hemorrhoidal vessel with acute swelling may allow blood to pool and, subsequently, clot; this leads to the acutely thrombosed external hemorrhoid (TEH), a bluish-purplish discoloration often accompanied by severe incapacitating pain. Although TEH is a common problem, it remains a poorly studied topic. Reported risk factors for TEH include a recent bout of constipation^1,2 and traumatic vaginal delivery.^3,4

Physicians: Peer Review this Article on Medscape Physician Connect.

Thrombosed hemorrhoid. Image courtesy of Dr. Jonathan Adler. This thrombosed hemorrhoid was treated by incision and removal of clot.

Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.

Although conservative nonsurgical treatment (stool softeners, increased dietary fiber, increased fluid intake, warm baths, analgesia) ultimately result in resolution of symptoms for most patients, surgical excision of the TEH may often be the best treatment.^5,6 In one retrospective study,⁷ surgical treatment resulted in much faster symptom resolution (3.9 d vs 24 d) as well as lower frequency of recurrence (6.3% vs 25.4%) in the study population. Another study⁸ demonstrated that, compared with simple incision or topically applied 0.2% glycerin trinitrate ointment, TEH excision improved recurrence rates, symptoms, and residual skin tags at 1-year follow-up.⁹

Newer conservative treatments such as topical nifedipine show promise over traditional conservative treatments such as lidocaine ointment;¹⁰ however, they have not yet been shown to decrease time to symptom resolution or frequency of recurrence as compared to surgical excision.

Surgical excision of the acutely thrombosed external hemorrhoid is within the purview of an office-based or emergency practitioner.

Indications

Acute pain and thrombosis of an external hemorrhoid within 48-72 hours of onset is an indication for excision.

Contraindications

Absolute contraindications to thrombosed external hemorrhoid excision in the emergency department include the following:

Any concern that the lesion may not be a thrombosed external hemorrhoid (including a painless rectal mass, since thrombosed external hemorrhoids are painful)
Grade IV internal hemorrhoid associated with a thrombosed external hemorrhoid
Known severe coagulopathy
Hemodynamic instability

Relative contraindications to emergency department excision of thrombosed external hemorrhoid include the following:

Allergy to local anesthetic
Perianal infection
Anorectal fissure
Portal hypertension
Inflammatory bowel disease
Known coagulopathy
Serious systemic illness or comorbidity that would significantly increase the risk of the procedure

Anesthesia

See Technique for details on local anesthesia.
For more information, see Local Anesthetic Agents, Infiltrative Administration.

Equipment

Direct dedicated lighting
Sterile gloves
Antiseptic solution with skin swabs
Sterile drape
Local anesthetic solution (0.5% bupivacaine or 1% lidocaine with epinephrine)
Syringe, 5 mL
Needles, 18 and 25 or 27 gauge
Small forceps for grasping tissue
Iris scissors to cut tissue or packing gauze
Scalpel blade on a handle, No. 11 or No. 15
Multiple 4 X 4 gauze squares
Adhesive tape, 2 inch
Absorbable suture, 3-0
Sterile packing gauze, quarter inch
Sterile dressing

Positioning

Position the patient in the prone or lateral decubitus position with the gurney at a height that accommodates the practitioner.

Technique

Explain the procedure, benefits, risks, complications, and alternatives to the patient, the patient's representative, or both. Obtain a signed informed consent. Ask the patient or the patient's representative if he or she would like others to be present for the procedure.
Position the patient prone on the gurney and use 2 overlapping sheets to cover the patient's buttocks. One sheet extends down the legs and the other extends up the back.
To increase exposure to the area, tape each buttock in a T pattern. First, place 2 long strips of tape (approximately 40 cm long) longitudinally on each buttock. These strips should extend from the lower back down to the upper thigh. Next, place another long strip of tape horizontally across the 2 vertically oriented strips. Pull the horizontal strips out to the side and tape them to the gurney.
Taping of patient prior to procedure (thrombosed external hemorrhoid is at the 9-o'clock position).
Prepare light source for sterile field.
Light source preparation for sterile field.
After cleaning the area with an alcohol swab, locally inject approximately 2-6 mL of local anesthesia (eg, lidocaine with epinephrine) at the base of the thrombosed hemorrhoid, and inject approximately 1-2 mL of the local anesthesia within the hemorrhoid.
Local anesthesia injected at hemorrhoid base and within the hemorrhoid.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-109642.flv.
Use skin swabs and antiseptic solution to clean the skin. Start at the hemorrhoid and work outward in progressively larger circles. Next, create a sterile field with sterile drapes surrounding the projected work area.
Application of povidone-iodine (Betadine) antiseptic.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-109643.flv.
Make an elliptical incision in the roof of the hemorrhoid, taking care to avoid the anal sphincter muscle. The incision should be directed radially from the anal orifice. The elliptical incision allows the thrombosed hemorrhoid to be unroofed. It is preferred over a simple incision and evacuation of clot because of the usual presence of multiloculated clots and their tendency to close and re-clot, if not unroofed.
Primary elliptical incision over hemorrhoid.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-110337.flv.
Remove the blood clot from the elliptical opening. Multiple clots are often present; all clots should be removed.
Further incision with removal of clot.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-110338.flv.
Use quarter-inch packing material to pack any space left by the removal of the clot. Take care not to pack tightly.
Gauze packing postprocedure.
Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-109646.flv.
Dress wound with 4 X 4 gauze pads folded over once and taped into place in a transverse fashion.
Dressing postexcision.
Dressing postexcision.

Pearls

Pain control is extremely important for this procedure. Assurance of adequate local anesthesia is important; at times, procedural sedation may be warranted.
Have rescue techniques (eg, suturing equipment, silver nitrate) at the bedside in case direct pressure does not control the bleeding.
Use direct lighting. Do not rely on ambient light alone.
Always make an elliptical incision rather than a simple incision to decrease the rate of complications.¹¹

Complications

Bleeding is probably the most common complication of this procedure and usually can be well controlled with direct pressure. If hemostasis is not obtained with direct pressure alone, either silver nitrate cauterization or a figure-of-eight stitch with an absorbable suture can be used.
Infection rate is not known but is believed to be less than 5%. Prophylactic antibiotics are not routinely indicated.
Perianal skin tag is a common benign complication after the incised area has healed.
Stricture is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle.
Incontinence is an uncommon complication that may be prevented by avoiding the underlying external anal sphincter muscle.
Pain is a common but avoidable complication. Any combination of parenteral and local anesthesia with or without procedural sedation may be used to avoid pain completely during this procedure.

Discharge Information

Patient should start sitz baths as soon as possible. Sitz baths should be taken 3-4 times a day for 20 minutes at a time in warm but not hot water.
Packing gauze can be removed in 48 hours if it has not yet fallen out.
Return precautions should be given both verbally and in written form. They should include the following:
- Uncontrolled pain
- Signs of infection (eg, pus, redness, fever)
- Moderate-to-severe bleeding (Minor bleeding is extremely common.)
Patient should begin taking some type of stool softener to avoid traumatic passage of feces. This should be continued for 2-4 weeks.
Acetaminophen or ibuprofen should be prescribed for pain control. Avoid opiate analgesics because of constipating and, thus, stool-hardening effects.
Antibiotics are not necessary.
A wound check is necessary if pain or bleeding persists for more than 36-48 hours postprocedure.

Multimedia

Media file 1: Taping of patient prior to procedure (thrombosed external hemorrhoid is at the 9-o'clock position).

Media file 2: Light source preparation for sterile field.

Media file 3: Local anesthesia injected at hemorrhoid base and within the hemorrhoid.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-109642.flv.

Media file 4: Application of povidone-iodine (Betadine) antiseptic.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-109643.flv.

Media file 5: Primary elliptical incision over hemorrhoid.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-110337.flv.

Media file 6: Further incision with removal of clot.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-110338.flv.

Media file 7: Gauze packing postprocedure.

Video available at http://img.medscape.com/pi/emed/ckb/clinical_procedures/79926-79936-81039-109646.flv.

Media file 8: Dressing postexcision.

Media file 9: Dressing postexcision.

Media file 10: Thrombosed hemorrhoid. Image courtesy of Dr. Jonathan Adler. This thrombosed hemorrhoid was treated by incision and removal of clot.

Media file 11: Anatomy of external hemorrhoid. Image courtesy of MedicineNet, Inc.

References

Oh C. Acute thrombosed external hemorrhoids. Mt Sinai J Med. Jan 1989;56(1):30-2. [Medline].
Tan KY, Seow-Choen F. Fiber and colorectal diseases: separating fact from fiction. World J Gastroenterol. Aug 21 2007;13(31):4161-7. [Medline].
Abramowitz L, Sobhani I, Benifla JL, Vuagnat A, Daraï E, Mignon M, et al. Anal fissure and thrombosed external hemorrhoids before and after delivery. Dis Colon Rectum. May 2002;45(5):650-5. [Medline].
Cheng CY, Li Q. Integrative review of research on general health status and prevalence of common physical health conditions of women after childbirth. Womens Health Issues. Jul-Aug 2008;18(4):267-80. [Medline].
Stites T, Lund DP. Common anorectal problems. Semin Pediatr Surg. Feb 2007;16(1):71-8. [Medline].
Alonso-Coello P, Mills E, Heels-Ansdell D, López-Yarto M, Zhou Q, Johanson JF, et al. Fiber for the treatment of hemorrhoids complications: a systematic review and meta-analysis. Am J Gastroenterol. Jan 2006;101(1):181-8. [Medline].
Greenspon J, Williams SB, Young HA, Orkin BA. Thrombosed external hemorrhoids: outcome after conservative or surgical management. Dis Colon Rectum. Sep 2004;47(9):1493-8. [Medline].
Cavcic J, Turcic J, Martinac P, Mestrovic T, Mladina R, Pezerovic-Panijan R. Comparison of topically applied 0.2% glyceryl trinitrate ointment, incision and excision in the treatment of perianal thrombosis. Dig Liver Dis. May 2001;33(4):335-40. [Medline].
Tan KY, Sng KK, Tay KH, Lai JH, Eu KW. Randomized clinical trial of 0.2 per cent glyceryl trinitrate ointment for wound healing and pain reduction after open diathermy haemorrhoidectomy. Br J Surg. Dec 2006;93(12):1464-8. [Medline].
Perrotti P, Antropoli C, Molino D, De Stefano G, Antropoli M. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. Mar 2001;44(3):405-9. [Medline].
Zuber TJ. Hemorrhoidectomy for thrombosed external hemorrhoids. Am Fam Physician. Apr 15 2002;65(8):1629-32, 1635-6, 1639. [Medline]. [Full Text].
Feldman M. Hemorrhoids. In: Sleisenger & Fordtran's Gastrointestinal and Liver Disease. 7^th ed. Elsevier; 2002:2281-82.
Reichman EF, Simon RR. External Hemorrhoid Management. In: Emergency Medicine Procedures. McGraw-Hill Medical Publishing; 2004:496-500.
Roberts JR, Hedges JR. Anorectal Procedures. In: Clinical Procedures in Emergency Medicine. 4^th ed. Philadelphia, PA: WB Saunders Company; 2004:871-4.

Keywords

hemorrhoid, thrombosed external hemorrhoid, hemorrhoid excision, hemroid, hemroids, hemorrhoid treatment, hemorrhoid surgery, external hemorrhoid, external hemorrhoids, hemorrhoid relief, thrombosed hemorrhoid, hemorrhoid pictures

Contributor Information and Disclosures

Author

Brett Wallace Lorber, MD, MPH, Staff Physician, Emergency Department, Olive View/UCLA Medical Center
Brett Wallace Lorber, MD, MPH is a member of the following medical societies: American College of Emergency Physicians
Disclosure: Nothing to disclose.

Coauthor(s)

Rick Kulkarni, MD, Assistant Professor of Surgery, Section of Emergency Medicine, Yale-New Haven Hospital
Rick Kulkarni, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: WebMD Salary Employment

Medical Editor

Erik D Schraga, MD, Consulting Staff, Department of Emergency Medicine, Mills-Peninsula Emergency Medical Associates; Consulting Staff, Permanente Medical Group, Kaiser Permanente, Santa Clara Medical Center
Disclosure: Nothing to disclose.

Pharmacy Editor

Mary L Windle, PharmD, Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy, Pharmacy Editor, eMedicine
Disclosure: Pfizer Inc Stock Investment from financial planner; Avanir Pharma Stock Investment from financial planner ; WebMD Salary and stock Employment and investment from financial planner

Managing Editor

Luis M Lovato, MD, Associate Clinical Professor, David Geffen School of Medicine at UCLA; Director of Critical Care, Department of Emergency Medicine, Olive View/UCLA Medical Center
Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

CME Editor

Gil Z Shlamovitz, MD, Assistant Professor of Emergency Medicine, University of Connecticut School of Medicine; Attending Physician, Emergency Department, Windham Community Memorial Hospital, Willimantic, CT; Attending Physician, Emergency Department, Hartford Hospital, Hartford, CT
Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians
Disclosure: Nothing to disclose.

Chief Editor

Further Reading

National Institute of Diabetes and Digestive and Kidney Disease, NIH: Hemorrhoids

National Library of Medicine, NIH: Hemorrhoids