Hemorrhoids

Hemorrhoids are dilated submucosal vascular cushions within the anal canal that can be asymptomatic or manifest as painless perianal masses, pruritus, or intermittent scant hematochezia (bright red blood per rectum, typically at the end of defecation). Excessive straining during defecation or intraabdominal pressure (e.g., due to constipation, pregnancy, or prolonged periods sitting) increase the likelihood of developing hemorrhoids. Based on their anatomical location, hemorrhoids are internal (above the dentate line), external (below the dentate line), or mixed. Internal hemorrhoids are classified into four grades according to the extent of prolapse. The diagnosis is primarily clinical, based on a thorough history and examination that includes a digital rectal examination and anoscopy. Further investigation with proctoscopy, sigmoidoscopy, or colonoscopy may be required to rule out differential diagnoses of hemorrhoids, including colorectal cancer. All patients with symptomatic hemorrhoids should be counseled on lifestyle modifications (e.g., increased fiber and fluid intake, regular physical activity) to reduce straining during defecation. Medical management also includes stool softeners and short-term use of topical medications (e.g., anesthetics, corticosteroids, or vasoconstrictors) for symptomatic relief. Hemorrhoids refractory to medical management and larger (grades III and IV) internal hemorrhoids typically require procedures such as rubber band ligation, sclerotherapy, and infrared coagulation, or surgery. Thrombosed external hemorrhoids manifest with acute pain and a tender bluish-purple perianal nodule. Surgical excision of the thrombosed hemorrhoid may be beneficial in patients who present within 3–4 days of symptom onset. Those who present later should be managed conservatively.

• Excessive straining; (e.g., from chronic constipation, frequent bowel movements, chronic cough, heavy lifting, benign prostatic hyperplasia)
• Extended periods of sitting (e.g., due to occupation or sedentary lifestyle)
• Pregnancy
• Older age
• Connective tissue disorder (e.g., Ehlers‑Danlos syndrome, scleroderma)

Anatomy of the anal canal

• Anal cushions
  • Areas of thickened anal mucosa that consist of arteriovenous blood vessels (corpus cavernosum recti), smooth muscle (e.g., Treitz muscle), and fibroelastic tissue (e.g., collagen, elastic fibers)
  • Located at 11, 7 and 3 o'clock in the lithotomy position (right anterior, right posterior, and left lateral position)
  • Play an important role in maintaining continence by enabling tight closure of the rectum
  • Defecation causes contraction of supportive structures (e.g., Treitz muscle) → compression of anal cushions → increased diameter of the anal canal for adequate passage of stool
• Anal columns: longitudinal folds of mucous membrane that are fused at their inferior ends by transverse folds (anal valves)
• Anal sinuses: small, mucus-secreting pouches between the anal columns above the anal valves
• Dentate line
  • Circular separation line formed by the fusion of anal valves (hindgut-proctodeum junction)
  • Divides anal canal into an upper and lower part (also see characteristics of the anal canal above and below the dentate line below)
• External anal sphincter
  • Composed of
    • Subcutaneous external sphincter: surrounds lower third of anal canal
    • Superficial external sphincter
    • Deep external sphincter
  • Consists of skeletal muscle and functions to open and close the anal canal and opening
  • Innervated by the pudendal nerve and under voluntary control
• Internal anal sphincter
  • Surrounds upper two-thirds of anal canal
  • Consists of involuntary circular smooth muscle and is responsible for ∼ 85% of the resting pressure of the anal canal
  • Innervated by the enteric nervous system

Internal vs. external hemorrhoids

Hemorrhoids are classified as internal , external , or mixed .

• Internal hemorrhoids
  • Prolapse of internal hemorrhoids, with possible incarceration and strangulation, may cause pain by triggering an anal sphincter complex spasm. → possible ischemia and necrosis of internal hemorrhoids → worsening anal sphincter complex spasm → potential external hemorrhoid thrombosis → cutaneous pain
  • Develop above the dentate line, which is not innervated by cutaneous nerves; distension does not cause pain.
  • Bleeding and/or prolapsed internal hemorrhoids irritate sensitive perianal skin → perianal itching
• External hemorrhoids
  • Develop below the dentate line, which is innervated by cutaneous nerves; distention; of this innervated skin due to thrombosis results in severe pain.
  • Acute thrombosis triggers cutaneous pain, lasting 7–14 days → thrombosis resolves → residual skin or skin tags of distended anal skin

Hemorrhoids are not varicose veins (dilated, tortuous veins). Anorectal varices occur, e.g., as a result of portal hypertension. The terms anorectal varices and hemorrhoids are often used interchangeably, but this is incorrect.

• Internal hemorrhoids
  • Often painless, bright red bleeding at the end of defecation
  • Perianal mass in the event of prolapse
  • Pruritus
  • Anal discharge (containing mucus or fecal debris)
  • Ulceration (in hemorrhoid stage IV)
• External hemorrhoids
  • Manifestations are similar to those of internal hemorrhoids (i.e., bright red bleeding, pruritus, perianal mass)
  • A thrombosed external hemorrhoid manifests with severe perianal pain and a tender perianal mass.

Internal hemorrhoids are graded according to extent of prolapse. There is no widely used classification system for external hemorrhoids.

Approach ^[5][6][7]

• All patients with suspected hemorrhoids: Perform a perianal examination, digital rectal examination, and anoscopy.
• Inconclusive initial evaluation: Refer for proctoscopy or flexible sigmoidoscopy to evaluate the rectum and distal colon.
• Concern for malignancy (age ≥ 50 years , risk factors for colorectal cancer, red flags for colorectal cancer): Colonoscopy (alternatively, CT colonography) is required to evaluate the entire colon. ^[6]

Hemorrhoids are a clinical diagnosis.

Physical examination ^[5][7][8]

• Evaluate in the prone jackknife position, lateral decubitus position, or lithotomy position. ^[8]
• Inspect the perianal area for external hemorrhoids and nonreduced internal hemorrhoids.
• Perform a digital rectal examination to evaluate for masses or tenderness.
• Ask the patient to perform the Valsalva maneuver in order to assess for any prolapse of grade II or III hemorrhoids or rectal mucosa.
• Rule out other potential sources of bright red blood per rectum or perianal masses (see “Differential diagnoses of hemorrhoids”).

Anoscopy ^[6][8]

• Insertion of an anoscope to directly visualize the anus and distal rectum ^[9]
• Perform in all patients with suspected hemorrhoids. ^[7][8]
• May show hemorrhoids or differential diagnoses, e.g., anal carcinoma or fissure

Further studies ^[6][8][10]

• Indications
  • Clinical uncertainty
  • Inadequate visualization on anoscopy
  • Concern for malignancy
• Modalities
  • High risk for malignancy : colonoscopy to visualize the entire colon; see “Initial workup” in “Approach to suspected colorectal cancer” for further information
  • Low risk for malignancy : proctoscopy or flexible sigmoidoscopy

• Anal skin tags: benign, painless folds of skin at the anal verge that are residues of previous episodes of inflammation or thrombosed hemorrhoids ^[5]
• Hypertrophied anal papillae
• Polyps
• Anal and colorectal carcinoma
• Anal fissures (cause painful bright red bleeding per rectum)
• Anorectal varices
• Proctitis
• Condyloma acuminata
• Inflammatory bowel disease (often associated with anal fistulas and abscesses)
• Rectal prolapse
• Perianal dermatitis

Always consider the possibility of concurrent colorectal carcinoma.

The differential diagnoses listed here are not exhaustive.

Approach ^[5][6][7]

• All patients with symptomatic hemorrhoids
  • Lifestyle modifications to reduce straining during defecation
  • Sitz baths and topical medications for short-term symptomatic relief
• Internal hemorrhoids
  • Grade I–III internal hemorrhoids unresponsive to conservative treatment: Refer for office-based procedures (e.g., rubber band ligation).
  • Grade IV internal hemorrhoids and those unresponsive to other therapies: Refer for surgery (e.g., hemorrhoidectomy, stapled hemorrhoidopexy).
• External hemorrhoids
  • Symptomatic external hemorrhoids refractory to conservative management: Refer for surgery.
  • Thrombosed external hemorrhoids
    • Presentation within 3–4 days of symptom onset: Consider excision of the thrombosed hemorrhoid.
    • Delayed presentation: conservative management

Hemorrhoids should only be treated in symptomatic patients. ^[6]

Medical management of hemorrhoids ^[5][6][7]

• Indications: all patients with hemorrhoids
• Interventions to reduce anorectal pressure and straining
  • Lifestyle modifications ^[5]
    • High fiber diet (20–30 g/day)
    • Increased fluid intake
    • Avoidance of fatty foods
    • Regular physical activity
    • Avoidance of excessive straining ^[11]
    • Limiting the amount of time spent on the toilet
  • Treatment of constipation with short-term (up to 1 week) use of stool softeners (e.g., docusate) or laxatives (e.g., polyethylene glycol 3350) as needed. ^[5]
• Interventions to alleviate symptoms (e.g., pain, pruritus)
  • Sitz baths: a bath in which the buttocks are immersed in warm water for short periods of time
  • Topical medications for short-term symptomatic relief: topical anesthetics (e.g., lidocaine), corticosteroids (e.g., hydrocortisone), and/or vasoconstrictors (e.g., phenylephrine)

Conservative management is often the only intervention required for grade I–II internal hemorrhoids and external hemorrhoids.

Long-term use of topical medications for hemorrhoids can lead to sensitization and localized reactions and should be avoided. ^[6]

Office-based procedures for hemorrhoids ^[5][6][8]

• Indications: grade I–III internal hemorrhoids with symptoms refractory to medical management ^[6]
• Interventions
  • Rubber band ligation: most common ^[5][6]
    • A rubber band at the base of an internal hemorrhoid under vision through an anoscope
    • Ligation leads to ischemic necrosis with subsequent fibrosis.
  • Sclerotherapy: low risk of bleeding; consider for patients on anticoagulants ^[5]
  • Infrared coagulation: application of infrared light waves to the base of the hemorrhoid under vision to induce necrosis and scar formation; typically performed for grade I–II internal hemorrhoids ^[6]
• Potential complications: uncommon; can include bleeding, pain, or infection (including perianal sepsis) ^[6]

Sclerotherapy may be preferable in patients with actively bleeding hemorrhoids who are on anticoagulants. ^[5]

Surgery for hemorrhoids ^[6][7]

• Indications ^[6][10]
  • Symptomatic grade III and IV internal hemorrhoids
  • Symptomatic external hemorrhoids or combined external and internal hemorrhoids with prolapse
  • No improvement after; , or inability to tolerate, medical and office-based interventions
• Options
  • Submucosal hemorrhoidectomy: surgical removal of hemorrhoids ^[12][13]
    • Ferguson approach (closed approach): The mucosal defect is closed (healing by primary intention) after excision of the hemorrhoid. ^[6]
    • Milligan‑Morgan approach (open approach): The mucosal defect is kept open (healing by secondary intention) after excision of the hemorrhoid.
  • Stapled hemorrhoidopexy (Longo procedure) ^[6][14]
    • A circular stapling device is used to remove a circular wedge of mucosal tissue above the dentate line
    • Only effective for internal hemorrhoids
  • Doppler-guided hemorrhoidal arterial ligation: identification and ligation of the arteries supplying hemorrhoids
• Potential complications: pain, bleeding, acute urinary retention, and rarely, anal stricture/stenosis

Pain is common after surgical treatment of hemorrhoids. Consider multimodal analgesia including local anesthesia and use of topical medications (e.g., diltiazem or nitroglycerin ointment) to reduce the need for opioid analgesics. ^[6]

Perianal sepsis can occur after surgical or office-based interventions for hemorrhoids and may manifest with worsening pain, fever, or dysuria. ^[6]

Definition

A thrombus within the inferior hemorrhoidal venous plexus distal to the dentate line

Pathophysiology

• Stasis of blood within the external hemorrhoid → thrombus formation → inflammation and distention of the overlying perianal skin → severe pain

External hemorrhoids are located distal to the dentate (pectinate) line and are drained by the inferior hemorrhoidal (rectal) plexus. External hemorrhoid thrombosis occurs if a clot forms in the inferior hemorrhoidal plexus. ^[15]

Clinical features ^[6][8][16]

• Acute onset of severe perianal pain
• Painful perianal mass that may ulcerate and bleed
• Painful defecation

Diagnostics ^[6]

• Typically a clinical diagnosis
• Perianal examination: a palpable, tender, dark red to purplish nodule at the anal verge or just within the anal canal

Management ^[5][6][8]

Surgical excision ^[12]

• Indication: severe perianal pain of less than 3–4 days duration ^[8]
• Contraindications (relative) ^[17][18]
  • Coagulopathy
  • Serious systemic illnesses
  • Hemodynamic instability
  • Concurrent anorectal disease
• Technique: excision of the thrombosed external hemorrhoid
• Complications
  • Bleeding
  • Infection
  • Recurrence ^[19]

Incision and drainage of a thrombosed external hemorrhoid is more likely to result in local recurrence; excision is the recommended surgical technique. ^[6][12]

Medical management ^[6][8]

• Indications
  • Patients who present after > 3–4 days of symptom onset
  • An alternative to surgery in patients with mild or moderate symptoms who present early
• Methods
  • Analgesia: warm sitz baths , antispasmodic agents (e.g., topical nitroglycerin or nifedipine) , analgesic creams (e.g., lidocaine)
  • Topical antiinflammatories: e.g., hydrocortisone cream
  • Improve passage of stool: stool softeners (e.g., docusate), increased intake of fluids and fiber

Hemorrhoids in pregnancy ^[15][20][21]

• Hemorrhoids are common in pregnant individuals.
• Management is typically conservative. ^[22]

Conservative management

• Provide medical management of hemorrhoids, including treatment of constipation. ^[22]
• Advise patients to:
  • Perform Kegel exercises to improve muscle tone. ^[23]
  • Lie on the left side to improve blood flow. ^[24]

Interventions

• When possible, defer office-based procedures for hemorrhoids and surgery for hemorrhoids until after the postpartum period. ^[25]
  • Hemorrhoids frequently self-resolve after delivery.
  • Surgery during pregnancy is associated with:
    • Induction of labor ^[15]
    • Increased bleeding risk ^[25]
    • Increased risk from sedation/anesthesia ^[20]
• Consider excision of thrombosed external hemorrhoids for acute thrombosis. ^[15][25]