AUTHOR AND EDITOR INFORMATION

Section 1 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

INTRODUCTION

Section 2 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Background

Hemorrhoidal disease is a common entity in the general population and in clinical practice. The most common cause of hematochezia in adults, it remains high in the differential diagnosis of almost any anorectal complaint.

Although hemorrhoids are very common, their true prevalence is unknown. Their presence may be underestimated due to the large proportion of relatively asymptomatic patients. Conversely, many nonspecific anorectal symptoms can be reflexively, and falsely, attributed to hemorrhoids without the appropriate workup.

The presentation of symptomatic hemorrhoids may be acute, chronic, or relapsing.

Pathophysiology

Hemorrhoids are a normal part of the human anorectum and arise from subepithelial connective tissue cushions within the anal canal.

Present in utero, these cushions surround and support distal anastomoses between the superior rectal arteries and the superior, middle, and inferior rectal veins. They also contain a subepithelial smooth muscle layer, contributing to the bulk of the cushions. Normal hemorrhoidal tissue accounts for approximately 15-20% of resting anal pressure and provides important sensory information, enabling the differentiation between solid, liquid, and gas.

Most people contain 3 of these cushions. Although classically described as lying in the right posterior (most common), right anterior, and left lateral positions, this combination is found in only 19% of patients. Hemorrhoids can be found at any position within the rectum.

Hemorrhoids are classified by their anatomic origin within the anal canal and by their position relative to the dentate line.

• Internal hemorrhoids develop above the dentate line from embryonic endoderm. They are covered by the simple columnar epithelium of anal mucosa and lack somatic sensory innervation.
• External hemorrhoids develop from ectoderm and arise distal to the dentate line. They are covered by stratified squamous epithelium and receive somatic sensory innervation from the inferior rectal nerve.
• Mixed hemorrhoids are confluent internal and external hemorrhoids.

Venous drainage of hemorrhoidal tissue mirrors embryologic origin:

• Internal hemorrhoids drain through the superior rectal vein into the portal system.
• External hemorrhoids drain through the inferior rectal vein into the inferior vena cava.
• Rich anastomoses exist between these 2 and the middle rectal vein, connecting the portal and systemic circulations.

Most symptoms arise from enlarged internal hemorrhoids. Abnormal swelling of the anal cushions causes dilatation and engorgement of the arteriovenous plexuses. This leads to stretching of the suspensory muscles and eventual prolapse of rectal tissue through the anal canal. The engorged anal mucosa is easily traumatized, leading to rectal bleeding that is typically bright red due to high blood oxygen content within the arteriovenous anastomoses. Prolapse leads to soiling and mucus discharge (triggering pruritus) and predisposes to incarceration and strangulation.

Most clinicians use the grading system proposed by Banov et al in 1985, which classifies internal hemorrhoids by their degree of prolapse into the anal canal. This system both correlates with symptoms and guides therapeutic approaches.

• Grade I hemorrhoids project into the anal canal and often bleed but do not prolapse.
• Grade II hemorrhoids may protrude beyond the anal verge with straining or defecating but reduce spontaneously when straining ceases.
• Grade III hemorrhoids protrude spontaneously or with straining and require manual reduction.
• Grade IV hemorrhoids chronically prolapse and cannot be reduced. They usually contain both internal and external components and may present with acute thrombosis or strangulation.

Frequency

United States

Prevalence is estimated at 4.4% in the general population.

Race

Patients presenting with hemorrhoidal disease are more frequently white, from higher socioeconomic status, and from rural areas.

Sex

No predilection is known, although men are more likely to seek treatment.

Age

External hemorrhoids occur more commonly in young and middle-aged adults than in older adults. The prevalence of hemorrhoids increases with age, with a peak in persons aged 45-65 years. Symptomatic hemorrhoids also increase in pregnancy, possibly due to direct pressure on the rectal veins.

CLINICAL

Section 3 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

History

The most common presentation of hemorrhoids is rectal bleeding, pain, pruritus, or prolapse. However, these symptoms are extremely nonspecific and may be seen in a number of anorectal diseases. The physician must therefore rely on a thorough history to help narrow the differential and must perform an adequate physical examination (including anoscopy when indicated) to confirm the diagnosis.

• An adequate history should include the onset and duration of symptoms. In addition to characterizing any pain, bleeding, protrusion or change in bowel habits, special attention should be placed on the patient's coagulation history and immune status.
• Bleeding is the most common presenting symptom. Blood is usually bright red and may drip or squirt into the toilet bowl. The physician should inquire about the quantity, color, and timing of any rectal bleeding. Darker blood or blood mixed with stool should raise suspicion of a more proximal cause of bleeding.
• A patient with a thrombosed external hemorrhoid may present with complaints of an acutely painful mass at the rectum (see Image 1). Pain truly caused by hemorrhoids usually arises only with acute thrombus formation. This pain peaks at 48-72 hours and begins to decline by the fourth day as the thrombus organizes. New-onset anal pain in the absence of a thrombosed hemorrhoid should prompt investigation for an alternate cause, such as an intersphincteric abscess or anal fissure. As many as 20% of patients with hemorrhoids will have concomitant anal fissures.
• The presence, timing, and reducibility of prolapse, when present, will help classify the grade of internal hemorrhoids and guide the therapeutic approach.
• • Grade I internal hemorrhoids are usually asymptomatic, but at times may cause minimal bleeding.
  • Grades II, III, or IV internal hemorrhoids usually present with painless bleeding but also may present with complaints of a dull aching pain, pruritus, or other symptoms due to prolapse.
• Familial predisposition, diet, history of constipation or diarrhea, and history of prolonged sitting or heavy lifting are also relevant, as are weight loss, abdominal pain, or any change in appetite or bowel habits. Presence of pruritus or any discharge should also be noted.

Physical

In addition to the general physical examination, physicians should also perform visual inspection of the rectum, digital rectal examination, and anoscopy or proctosigmoidoscopy when appropriate.

The preferred position for the digital rectal examination is the left lateral decubitus with the patient's knees flexed toward the chest. Topical anesthetics (eg, 20% benzocaine or 5% lidocaine ointment) may help to reduce any discomfort caused by examination.

• External findings important to note include any of the following:
• • Redundant tissue
  • Skin tags from old thrombosed external hemorrhoids
  • Fissures
  • Fistulas
  • Signs of infection or abscess formation
  • Rectal or hemorrhoidal prolapse, appearing as a bluish, tender perianal mass
• During the digital rectal examination, assess for any masses, tenderness, mucoid discharge or blood, and rectal tone. Internal hemorrhoids are usually not palpable unless thrombosed.
• Current guidelines from most gastrointestinal and surgical societies advocate anoscopy and/or flexible sigmoidoscopy to evaluate any bright-red rectal bleeding. Colonoscopy should be considered in the evaluation of any rectal bleeding that is not typical of hemorrhoids such as in the presence of strong risk factors for colonic malignancy or in the setting of rectal bleeding with a negative anorectal examination.

Causes

Although many patients and clinicians believe that hemorrhoids are caused by chronic constipation, prolonged sitting, and vigorous straining, little evidence to support a causative link exists.

• Other risk factors historically associated with the development of hemorrhoids include the following:
• • Pregnancy
  • Lack of erect posture
  • Familial tendency
  • Higher socioeconomic status
  • Chronic diarrhea
  • Colon malignancy
  • Hepatic disease
  • Obesity
  • Elevated anal resting pressure
  • Spinal cord injury
  • Loss of rectal muscle tone
  • Rectal surgery
  • Episiotomy
  • Anal intercourse
• Varicosities caused from portal hypertension are a distinct entity from hemorrhoids.

DIFFERENTIALS

Section 4 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Other Problems to be Considered

Anal cancer
Anal fissure
Anal fistula
Pedunculated polyp
Perianal abscess
Pruritus ani
Colorectal tumors

WORKUP

Section 5 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Lab Studies

• A CBC may be useful as a marker for infection. Anemia due to hemorrhoidal bleeding is rare (0.5 cases per 100,000 patients), and its presence should raise suspicion of an alternate diagnosis.

Imaging Studies

• Proctogram may be indicated in rectal prolapse.

Procedures

• Proctoscopy may be performed to supplement anoscopy.
• Full evaluation of the large bowel with colonoscopy is recommended for patients with significant abdominal symptoms, weight loss, change in bowel habits, age older than 50 years, or other risk factors for colonic malignancy.

TREATMENT

Section 6 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Emergency Department Care

Medical management is the initial treatment of choice for grade I internal and nonthrombosed external hemorrhoids. It consists of sitz baths (bid/tid); a high-fiber diet; adequate fluid intake; stool softeners; topical and systemic analgesics; proper anal hygiene; and in some cases, a short course of topical steroid cream. Good evidence exists that high fiber diets in particular help reduce severity and duration of symptoms. The prolonged use of topical steroids should be avoided.

• Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset.
  • Infiltration of a local anesthetic containing epinephrine is followed by elliptical incision and excision of the thrombosed hemorrhoid and overlying skin. Simple incision and clot evacuation is inadequate therapy and should not be performed.
  • The incision should not extend beyond the anal verge or deeper than the cutaneous layer. A pressure dressing is applied for several hours, after which time the wound is left to heal by secondary intention.
  • In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable.
• Internal hemorrhoids are treated according to their classification. Treatment may be surgical or nonsurgical. Most nonsurgical procedures currently available are performed in the clinic or ambulatory setting.
  • Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods.
  • Grade II or III hemorrhoids are initially treated with nonsurgical procedures.
  • Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy.
• Nonsurgical techniques function by ablation, sclerosis, or necrosis of mucosal tissues. Despite several meta-analyses and considerable personal preference, there is no clear advantage of one technique over the others.
  • Rubber band ligation is the most-used remedy for grade II and grade III hemorrhoids and is the standard to which other methods are compared. A band ligature is passed through an anoscope and placed on the rectal mucosa proximal to the dentate line. The tissue necroses and sloughs off in 1-2 weeks, leaving an ulcer that later fibroses. No anesthesia is required; complications are uncommon and usually benign.
  • Necrotizing pelvic sepsis is a rare, but serious, complication of rubber band ligation. The diagnosis is suggested by the triad of severe pain, fever, and urinary retention. It occurs 1-2 weeks after ligation, frequently in immune compromised patients, and requires prompt surgical debridement.
  • Infrared coagulation serves best for grade I, grade II, and some grade III hemorrhoids. It may be as effective as banding with fewer and less severe complications.
  • Bipolar electrocautery is best for lower-grade hemorrhoids; it quickly coagulates the hemorrhoid tissue but has no effect on prolapse.
  • Low-voltage direct current works best for higher grade hemorrhoids. Low-voltage direct current requires grounding time and provides excellent control of pain.
  • Sclerotherapy and cryotherapy are infrequently used today and generally reserved for type I or II hemorrhoids. Although minimally invasive, they have a higher rate of post-procedure pain. Impotence, urinary retention, and abscess formation have also been reported. Recurrence rates are as high as 30%.
  • Laser therapy is more costly and provides no advantage over other methods. Operators must control the laser to avoid bleeding.
• Contraindications to the nonsurgical treatments listed above include the following:
  • AIDS
  • Immunodeficiency disorders
  • Coagulopathy
  • Irritable bowel disease
  • Pregnancy
  • Immediate postpartum period
  • Rectal wall prolapse
  • Large anorectal fissure or infection
  • Tumor
• Surgical hemorrhoidectomy is the most effective treatment for all hemorrhoids and in particular is indicated in the following situations:
  • Nonsurgical treatment fails (persistent bleeding or chronic symptoms)
  • Grade III and IV hemorrhoids with severe symptoms
  • Presence of concomitant anorectal conditions (eg, anal fissure or fistula) requiring surgery
  • Patient preference
• About 5-10% of people with hemorrhoids will eventually require surgical hemorrhoidectomy. Postoperative pain remains the major complication, with most patients requiring 2-4 weeks before returning to normal activities. Other possible complications include urinary retention, anal stenosis, and incontinence.

Consultations

Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation.

MEDICATION

Section 7 of 10  

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• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

The goals of therapy are to reduce pain and constipation.

Drug Category: Stool softeners

These agents are used to avoid straining and constipation.

Drug Category: Topical anesthetics

These agents are indicated for pain.

Drug Category: Mild astringent

This agent is used to relieve itching.

Drug Category: Analgesics

Pain control is essential to quality patient care. Analgesics ensure patient comfort, which is beneficial for patients who have painful lesions.

FOLLOW-UP

Section 8 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Further Outpatient Care

• After excision of a thrombosed external hemorrhoid, the patient may be discharged home for several hours of bedrest followed by sitz baths tid, stool softeners, and topical or systemic analgesia. The patient should return in 48-72 hours for a wound check.
• All other patients should be referred to a surgical or rectal clinic for more definitive treatment and sent home with conservative medical therapy.

Deterrence/Prevention

• Avoid constipation
• Weight loss
• Avoid prolonged sitting on the toilet
• Avoid prolonged sitting at work
• Improved anorectal hygiene

Complications

• Thrombosis
• Secondary infection
• Ulceration
• Abscess
• Incontinence

Prognosis

• Most hemorrhoids resolve spontaneously or with conservative medical therapy alone.
• Recurrence rate with nonsurgical techniques is 10-50% over a 5-year period, while that of surgical hemorrhoidectomy is approximately 26%.

Patient Education

• For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Hemorrhoids, Anal Abscess, Rectal Pain, and Rectal Bleeding.

MULTIMEDIA

Section 9 of 10  

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

Media file 1:  Thrombosed hemorrhoid. This hemorrhoid was treated by incision and removal of clot.
	View Full Size Image
Media type:  Photo

REFERENCES

Section 10 of 10

• Authors and Editors
• Introduction
• Clinical
• Differentials
• Workup
• Treatment
• Medication
• Follow-up
• Multimedia
• References

• Billingham RP, Isler JT, Kimmins MH. The diagnosis and management of common anorectal disorders. Curr Probl Surg. Jul 2004;41(7):586-645. [Medline].
• Fazio VW, Tjandra JJ. The management of perianal diseases. Adv Surg. 1996;29:59-78. [Medline].
• Janicke DM, Pundt MR. Anorectal disorders. Emerg Med Clin North Am. Nov 1996;14(4):757-88. [Medline].
• MacKay D. Hemorrhoids and varicose veins: a review of treatment options. Altern Med Rev. Apr 2001;6(2):126-40. [Medline].
• Madoff RD, Fleshman JW. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology. May 2004;126(5):1463-73. [Medline].
• Metcalf A. Anorectal disorders. Five common causes of pain, itching, and bleeding. Postgrad Med. Nov 1995;98(5):81-4, 87-9, 92-4. [Medline].
• Parker GS. A new treatment option for grade II and IV hemorrhoids. J Fam Pract. Oct 2004;53(10):799-804. [Medline].
• Perrotti P, Antropoli C, Molino D, et al. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum. Mar 2001;44(3):405-9. [Medline].
• Pfenninger JL, Surrell J. Nonsurgical treatment options for internal hemorrhoids. Am Fam Physician. Sep 1 1995;52(3):821-34, 839-41. [Medline].
• Scaglia M, Delaini GG, Destefano I, Hulten L. Injection treatment of hemorrhoids in patients with acquired immunodeficiency syndrome. Dis Colon Rectum. Mar 2001;44(3):401-4. [Medline].

Article Last Updated: Apr 20, 2006