Hemorrhoidectomy for Histopathological Examination
No, hemorrhoidectomy is not always necessary for histopathological examination—routine histopathology of hemorrhoid specimens is not recommended due to the extremely low incidence of malignancy (0.13%) and lack of impact on postoperative management in the vast majority of cases. 1, 2
Evidence Against Routine Histopathology
The most recent systematic review and meta-analysis of 48,365 hemorrhoidectomy specimens found that anal cancer was detected in only 0.13% (95% CI: 0.05%-0.31%) of cases, and combined anal cancer with anal intraepithelial neoplasia (AIN) occurred in just 1.16% (95% CI: 0.53%-2.52%) of specimens. 2
A large retrospective study of 914 hemorrhoidectomy specimens found histologic abnormalities in only 1.4% of cases, and critically, none of these findings altered postoperative management. 1
The low incidence of malignant findings suggests that routine histopathological analysis of hemorrhoidectomy samples is not cost-effective. 2
Clinical Implications for Practice
Hemorrhoidectomy should be performed based on clinical indications—not for the purpose of obtaining tissue for histopathology. The American Gastroenterological Association recommends surgical hemorrhoidectomy for:
- Large third-degree or fourth-degree hemorrhoids 3
- Acutely incarcerated and thrombosed hemorrhoids 3
- Hemorrhoids with extensive symptomatic external components 3
- Failure of less aggressive therapy 3
- Mixed internal and external hemorrhoids requiring definitive treatment 4
When Histopathology May Be Warranted
While routine histopathology is unnecessary, selective examination should be considered when clinical features raise suspicion for alternative pathology:
- Atypical appearance of tissue at time of excision 5
- Unusual bleeding patterns not consistent with typical hemorrhoidal disease 5
- Presence of anal pain (which is generally not associated with uncomplicated hemorrhoids and suggests other pathology such as anal fissure, abscess, or malignancy) 4
- Patient age over 60 years with concerning features 1
- Off-midline lesions that could represent Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, leukemia, or cancer 4
Important Diagnostic Caveats
Never assume all anorectal symptoms are due to hemorrhoids—a directed physical examination including anoscopy and proctosigmoidoscopy should be performed to rule out other conditions. 3, 5
- Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated. 4, 5
- Anemia from hemorrhoidal disease is rare (0.5 patients per 100,000 population) and should prompt colonoscopy to exclude proximal colonic pathology. 4, 5
- Significant anal pain is not typical of uncomplicated hemorrhoids and warrants investigation for anal fissure (present in up to 20% of patients with hemorrhoids), abscess, or thrombosis. 4
Cost-Effectiveness Considerations
The existing literature has not established definitive risk factors for abnormal histological diagnoses that would justify selective histopathology protocols. 2 Given the extremely low yield of clinically significant findings and the lack of impact on postoperative management in 98.6% of cases 1, routine histopathological examination represents an unnecessary healthcare expenditure without meaningful benefit to patient outcomes in terms of morbidity, mortality, or quality of life.