What are the indications for a hemorrhoidectomy in adults, particularly those over 50 with a history of constipation, pregnancy, or prolonged sitting, and who have tried other treatments?

Indications for Hemorrhoidectomy

Hemorrhoidectomy is indicated for symptomatic grade III-IV internal hemorrhoids that have failed conservative and office-based treatments, mixed internal and external hemorrhoids, hemorrhoids causing anemia from chronic bleeding, and acutely thrombosed/incarcerated hemorrhoids. 1

Primary Indications

Grade-Based Indications

• Grade III-IV internal hemorrhoids that remain symptomatic despite conservative management and office-based procedures represent the clearest indication 1, 2
• Grade III hemorrhoids requiring manual reduction and grade IV irreducible hemorrhoids are particularly appropriate for surgical intervention 1, 2
• Mixed internal and external hemorrhoids where the external component causes persistent symptoms unresponsive to conservative therapy 1

Failure of Conservative Therapy

• Patients who have undergone adequate trial of dietary modifications (increased fiber to 25-30g daily, adequate water intake) and lifestyle changes without improvement 1
• Failure of office-based procedures including rubber band ligation, sclerotherapy, or infrared photocoagulation 1, 2
• Rubber band ligation typically achieves 70-89% success rates for grade II-III hemorrhoids, so persistent symptoms after proper banding attempts warrant surgical consideration 1

Hemorrhoidal Complications

• Anemia from chronic hemorrhoidal bleeding with documented low hemoglobin and active bleeding on anoscopy 1
• Anemia from hemorrhoids is rare (0.5 per 100,000 population) but represents a critical threshold demanding definitive intervention 1
• Acutely prolapsed, incarcerated, and thrombosed internal hemorrhoids that cannot be reduced 1
• Thrombosed external hemorrhoids presenting within 72 hours of symptom onset (complete excision under local anesthesia preferred over simple incision/drainage) 1, 2

Concomitant Conditions

• Presence of other anorectal pathology requiring surgical intervention (anal fissure, fistula, abscess) that can be addressed simultaneously 1
• Multiple hemorrhoid columns suggesting extensive disease less amenable to office procedures 1

Important Clinical Considerations

Patient Selection Factors

• Age over 50 with risk factors (constipation, pregnancy history, prolonged sitting) who have exhausted conservative options are appropriate candidates 1
• Immunocompromised patients require careful risk-benefit assessment due to increased complication risk 1
• Patient preference after thorough discussion of treatment options, recovery time (2-4 weeks off work), and postoperative pain requiring narcotic analgesics 1, 3

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to exclude proximal colonic pathology including malignancy 1
• Do not delay definitive treatment when active bleeding has caused anemia, as continued blood loss will occur 1
• Avoid assuming all anorectal symptoms are hemorrhoids—anal fissures coexist in up to 20% of hemorrhoid patients 1
• Simple incision and drainage of thrombosed hemorrhoids is contraindicated due to persistent bleeding and higher recurrence rates; complete excision is required 1, 2

Surgical Outcomes

• Conventional excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson techniques) achieves 2-10% recurrence rates, the lowest among all treatment modalities 1, 3, 2
• Success rates approach 90-98% for properly selected patients 1
• Complication rates include urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%) 1

Alternative Surgical Approaches

• Stapled hemorrhoidopexy may be considered for circumferential grade III-IV hemorrhoids, offering less postoperative pain and faster recovery, though long-term efficacy data are limited 1, 3
• Hemorrhoidal artery ligation may be useful for grade II-III disease with potentially less pain and quicker recovery 4
• Avoid anal dilatation due to 52% incontinence rate at 17-year follow-up 1, 3