What Are Hemorrhoids?
Hemorrhoids are the symptomatic enlargement and abnormal displacement of normal vascular structures (anal cushions) that line the anal canal, consisting of connective tissue surrounding arteriovenous communications between terminal branches of the superior rectal arteries and rectal veins. 1
Anatomical Classification
- Internal hemorrhoids develop above the dentate line from the anal cushions and typically present with painless bright red bleeding and tissue prolapse, graded I-IV based on severity 2, 3
- External hemorrhoids arise below the dentate line from perianal marginal veins and become symptomatic primarily when thrombosed, causing acute severe pain and a palpable perianal lump 2, 3, 4
Grading System for Internal Hemorrhoids
- First-degree: Bleeding without prolapse 2, 3
- Second-degree: Prolapse with spontaneous reduction (with or without bleeding) 2, 3
- Third-degree: Prolapse requiring manual reduction 2, 3
- Fourth-degree: Irreducible prolapse, usually involving both internal and external components; includes acutely thrombosed, incarcerated hemorrhoids 2, 3
Pathophysiology
- Symptomatic hemorrhoids develop when anal cushions become abnormally enlarged, leading to stretching of suspensory muscles and dilation of the submucosal arteriovenous plexus, though the exact mechanism remains incompletely understood 1
- Elevated anal resting pressure has been consistently demonstrated in patients with hemorrhoids, though whether this causes or results from the condition is unclear; resting tone normalizes after hemorrhoidectomy 1
- The bright red bleeding characteristic of hemorrhoids results from arterial oxygen tension caused by arteriovenous communications within the anal cushions 1
Common Contributing Factors (Though Rigorous Proof Is Lacking)
- Inadequate fiber intake, prolonged sitting on the toilet, and chronic straining at stool are widely believed to contribute but lack rigorous scientific proof 1
- Constipation, diarrhea, and family history have been proposed but not rigorously proven 1
- Pregnancy is associated with hemorrhoids in approximately 80% of pregnant persons, more commonly during the third trimester due to compression of the rectum by the gravid uterus 1
How Hemorrhoids Are Treated
First-Line Conservative Management (For All Grades)
All hemorrhoids should initially be managed conservatively with dietary and lifestyle modifications before considering procedural or surgical interventions. 3, 5
Dietary and Lifestyle Modifications
- Increase dietary fiber to 25-30 grams daily (achievable with 5-6 teaspoonfuls psyllium husk mixed with 600 mL water daily) to soften stool and reduce straining 3, 5
- Increase water intake adequately to soften stool 3, 5
- Avoid prolonged sitting on the toilet and straining during defecation 3
- Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 3
Topical Treatments for Symptom Relief
- Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone for thrombosed external hemorrhoids 3, 5
- Topical analgesics containing lidocaine (1.5-2% concentration) provide symptomatic relief of local pain and itching 3, 5
- Corticosteroid creams may reduce local perianal inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 3, 5
- Topical nitrates show good results but are limited by high incidence of headache (up to 50% of patients) 3
Oral Medications
- Flavonoids (phlebotonics) relieve bleeding, pain, and swelling through improvement of venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 3
- Bulk-forming agents like psyllium husk help regulate bowel movements 3
- Over-the-counter oral analgesics (acetaminophen or ibuprofen) for additional pain control 3
Important Caveat About Suppositories
- Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 3
- Long-term use of high-potency corticosteroid suppositories is potentially harmful and should be avoided 3
Office-Based Procedures (When Conservative Management Fails)
Rubber Band Ligation (Preferred First Procedural Intervention)
Rubber band ligation is the most effective office-based procedure for persistent grade I-III internal hemorrhoids after conservative management fails, with success rates of 70.5-89%. 3, 5
- Works by tightly encircling redundant mucosa, connective tissue, and blood vessels, causing tissue necrosis and subsequent scarring that fixes tissue to the rectal wall 3
- The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerve afferents are absent above the anal transition zone 3
- Can be performed in an office setting without anesthesia 3
- Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer to limit treatment to 1-2 columns at a time 3
- More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 3
Contraindications: Immunocompromised patients (including those with uncontrolled AIDS, neutropenia, and severe diabetes mellitus) have increased risk of necrotizing pelvic infection 3
Other Office-Based Procedures
- Injection sclerotherapy is suitable for first and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage 3
- Infrared photocoagulation has success rates of 67-96% for first or second-degree hemorrhoids but requires more repeat treatments 3
- Bipolar diathermy has success rates for bleeding control of 88-100% in patients with grade II internal hemorrhoids 3
Surgical Management
Indications for Surgery
Hemorrhoidectomy is indicated for: 3, 5
- Failure of medical and non-operative therapy
- Symptomatic third or fourth-degree hemorrhoids
- Mixed internal and external hemorrhoids
- Severe or persistent bleeding not controlled by other methods
- Anemia from hemorrhoidal bleeding
- Concomitant anorectal conditions requiring surgery (fissure, fistula)
Surgical Options
- Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) is the most effective treatment overall, particularly for third-degree hemorrhoids, with a low recurrence rate of 2-10% 3, 5
- Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 3
- Stapled hemorrhoidopexy shows promising results but lacks long-term follow-up data 3
Procedures to Avoid
- Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 3
- Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 3
Management of Thrombosed External Hemorrhoids
Early Presentation (Within 72 Hours of Symptom Onset)
Complete surgical excision under local anesthesia is the treatment of choice for thrombosed external hemorrhoids presenting within 72 hours, providing faster pain relief and lower recurrence rates compared to conservative management. 3, 5
- Can be safely performed as an outpatient procedure with low complication rates 3
- Never perform simple incision and drainage of the thrombus alone—this leads to persistent bleeding and significantly higher recurrence rates 3, 5
Late Presentation (>72 Hours After Onset)
Conservative management is preferred for presentation beyond 72 hours, as the natural resolution process has typically begun. 3, 5
- Treatment includes stool softeners, oral and topical analgesics 3
- Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks shows 92% resolution rate 3
- Sitz baths and over-the-counter analgesics for pain management 3
Special Considerations for Pregnancy
- Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 3, 1
- Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 3
- Osmotic laxatives such as polyethylene glycol or lactulose can be used safely during pregnancy 3
- Hydrocortisone foam can be used safely in the third trimester with no adverse events 3
- Only 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids 1
What Ways NOT to Hinder Healing
Critical Behaviors to Avoid
Straining and Constipation
Avoiding straining during defecation is the single most crucial factor in preventing hemorrhoid exacerbation and promoting healing. 3, 5
- Straining is the most common trigger for postoperative bleeding after hemorrhoidectomy 3
- Maintain soft, bulky stools through adequate fiber (25-30g daily) and water intake 3, 5
- Use bulk-forming agents like psyllium husk to prevent straining 3
Prolonged Toilet Sitting
- Avoid prolonged sitting on the toilet, as this is widely believed to contribute to hemorrhoid symptoms (though rigorous proof is lacking) 1
Medication Misuse
- Never use corticosteroid creams for more than 7 days—prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury and hindering healing 3, 5
- Avoid long-term use of high-potency corticosteroid suppositories as they are potentially harmful 3, 5
Physical Activity Considerations
- Patients with acute, thrombosed hemorrhoids should temporarily avoid strenuous exercise until symptoms resolve 3
- Once symptoms improve, moderate cardio exercise such as walking, swimming, or cycling for 20-45 minutes, 3-5 times per week is beneficial 3
Positive Measures to Promote Healing
Hygiene and Comfort Measures
- Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 3, 5
- Gentle cleaning with warm water and mild soap after bowel movements 5
- Apply direct pressure if active bleeding is present 5
Dietary Optimization
- Combine exercise with increased dietary fiber and adequate water intake to produce soft, bulky stools 3
- Maintain fiber intake of 25-30 grams daily consistently 3, 5
Appropriate Topical Treatment
- Use topical 0.3% nifedipine with 1.5% lidocaine ointment as directed (every 12 hours for two weeks) for optimal healing 3, 5
- Apply topical analgesics containing lidocaine for pain and itching relief as needed 3, 5
When to Seek Immediate Medical Attention
If symptoms worsen or fail to improve within 1-2 weeks of treatment, or if any of the following occur, further evaluation is necessary: 3, 5
- Significant bleeding with signs of hemodynamic instability (dizziness, tachycardia, hypotension) 3
- Severe pain with high fever and urinary retention (suggests necrotizing pelvic sepsis) 3
- Development of anemia symptoms (extreme fatigue, pallor, shortness of breath) 3
- Inability to reduce prolapsed tissue 2
Critical Diagnostic Pitfalls to Avoid
- Never attribute all anorectal symptoms to hemorrhoids—up to 20% of patients with hemorrhoids have concomitant anal fissures 2, 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 3, 5
- Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population)—never attribute anemia to hemorrhoids without proper evaluation, and colonoscopy should be performed to rule out proximal colonic pathology 3
- Anal pain is generally not associated with uncomplicated hemorrhoids—its presence suggests other pathology such as anal fissure, abscess, or thrombosis 2, 3, 5
- Complete colonic evaluation by colonoscopy is indicated when bleeding is atypical for hemorrhoids or when the patient has significant risk factors for colonic neoplasia 3, 5