INTRODUCTION

Section 2 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Hemorrhoids have plagued humankind since time immemorial, yet many misunderstandings regarding hemorrhoidal complaints and disease still exist. Many laypersons and physicians do not understand the anorectal area and the common diseases associated with it.

This article discusses internal and external hemorrhoids and their associated symptoms.

For excellent patient education resources, visit eMedicine's Esophagus, Stomach, and Intestine Center. Also, see eMedicine's patient education articles Hemorrhoids, Inflammatory Bowel Disease, Rectal Pain, and Rectal Bleeding.

Frequency

Ten million people in the United States have hemorrhoids, leading to a prevalence of greater than 4%. Up to one third of these people seek medical treatment, resulting in 1.5 million prescriptions per year.

The number of hospital hemorrhoidectomies is declining. A peak of 117 hemorrhoidectomies per 100,000 people was reached in 1974; this rate declined to 37 hemorrhoidectomies per 100,000 people in 1987. Obviously, outpatient and office treatment of hemorrhoids account for some of this decline.

The peak age is 45-65 years; however, hemorrhoids plague all age groups.

Etiology

Hemorrhoidal complaints are usually not associated with other medical conditions or diseases.  Patients with the following diseases and conditions have an increased risk of hemorrhoidal complaints:

• Inflammatory bowel disease and hemorrhoidal problems occur frequently. Unusual hemorrhoidal presentations and findings should alert the clinician to the potential of inflammatory bowel disease.
• Ulcerative colitis and Crohn disease are associated with hemorrhoids.
• Pregnancy is associated with many anorectal problems.

Pathophysiology

The term hemorrhoid is usually related to symptoms caused by hemorrhoids. Hemorrhoids are present in healthy individuals. In fact, hemorrhoidal columns are present in utero.  When these vascular cushions produce symptoms, most laypersons and physicians refer to them as hemorrhoids. Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed.

Most authors agree that low-fiber diets cause small-caliber stools, which result in straining with defecation. This increased pressure causes engorgement of the hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause hemorrhoidal problems, presumably by means of the same mechanism. Decreased venous return is thought to be the mechanism of action. Prolonged sitting on a toilet (eg, while reading) is believed to cause a relative venous return problem in the perianal area (a tourniquet effect), resulting in enlarged hemorrhoids. Aging causes weakening of the support structures, which facilitates prolapse. Weakening of support structures can occur as early as the third decade of life.

Straining and constipation have long been thought of as culprits in the formation of hemorrhoids. This may or may not be true. Patients who report hemorrhoids have a canal-resting tone that is higher than normal. Of interest, the resting tone is lower after hemorrhoidectomy than before. This change in the resting tone is the mechanism of action of Lord dilatation.  This is a surgical procedure for anorectal complaints that is most commonly performed in the United Kingdom.

Pregnancy clearly predisposes women to symptoms from hemorrhoids, although the etiology is unknown. Notably, most patients will revert to their previously asymptomatic state after delivery. The relationship between pregnancy and hemorrhoids lends credence to hormonal changes or direct pressure as the culprit.

Portal hypertension has often been mentioned in conjunction with hemorrhoids. Hemorrhoidal symptoms do not occur more frequently in patients with portal hypertension than in those without. Massive bleeding from hemorrhoids in these patients is unusual. Bleeding is very often complicated by coagulopathy. If bleeding is found, direct suture ligation of the offending column is suggested.

Anorectal varices are common in patients with portal hypertension. Varices occur in the mid rectum, at connections between the portal system and the middle and inferior rectal veins. Varices occur more frequently in patients who are noncirrhotic, and they rarely bleed. Treatment is usually directed at the underlying portal hypertension. Emergent control of bleeding can be obtained with suture ligation. Portosystemic shunts and, more recently, transjugular intrahepatic portosystemic shunts (TIPS) have been used to control hypertension and, thus, the bleeding.

Clinical

Most laypersons and many physicians attribute all perianal symptoms to hemorrhoids. The astute physician can often listen to a patient's description of symptoms and ascertain the source of the problem or condition before confirmatory examination. Nonhemorrhoidal causes of symptoms (eg, fissure, abscess, fistula, pruritus ani, condylomata, viral and bacterial skin infections) need to be excluded.

Hemorrhoidal symptoms are divided into internal and external sources. Internal hemorrhoids cannot cause cutaneous pain, as they are above the dentate line and are not innervated by cutaneous nerves. They can bleed, prolapse and cause perianal itching and irritation. Irritation and itching is caused by deposition of an irritant onto the sensitive perianal skin.  Internal hemorrhoids can cause perianal pain by prolapsing and causing spasm of the sphincter complex around the hemorrhoids. This spasm results in discomfort while the prolapsed hemorrhoids are exposed. This muscle discomfort is relieved with reduction. Internal hemorrhoids can also cause acute pain when incarcerated and strangulated. Again, the pain is related to the sphincter complex spasm. Strangulation with necrosis may cause more deep discomfort. When these catastrophic events occur, the sphincter spasm often causes concomitant external thrombosis. External thrombosis causes acute cutaneous pain. This consternation of symptomsis referred to as acute hemorrhoidal crisis. It usually requires emergent treatment.

Internal hemorrhoids most commonly cause painless bleeding with bowel movements. The covering epithelium is damaged by the hard bowel movement and the underlying veins bleed. With spasm of the sphincter complex elevating pressure, the internal hemorrhoidal veins can spurt.

Internal hemorrhoids can deposit mucus onto the perianal tissue with prolapse. This mucus with microscopic stool contents can cause a localized dermatitis, which is called pruritus ani. Generally, hemorrhoids are merely the vehicle by which the offending elements reach the perianal tissue. Hemorrhoids are not the primary offenders.

External hemorrhoids cause symptoms in 2 ways. First, acute thrombosis of the underlying external hemorrhoidal vein can occur. Acute thrombosis is usually related to a specific event, for example, physical exertion, straining with constipation, a bout of diarrhea, or a change in diet. These are acute, painful events. Pain results from rapid distension of innervated skin by the clot and surrounding edema. The pain lasts 7-14 days and resolves with resolution of the thrombosis. With resolution of the thrombosis, the stretched anoderm persists as excess skin or skin tags. External thromboses can occasionally erode the overlying skin and cause bleeding. Recurrence occurs approximately 40-50% of the time, at the same site. This occurs at the same site because the underlying damaged vein remains present. Simply removing the blood clot and leaving the weakened vein in place, compared with excision of the offending vein with the clot, will predispose to recurrence.

External hemorrhoids can also cause trouble with hygiene. The excess redundant skin left after an acute thrombosis (skin tags) is actually accountable for these problems. External hemorrhoidal veins found under the perianal skin obviously cannot cause hygiene problems; however, excess skin in the perianal area can mechanically interfere with cleansing.

INDICATIONS

Section 3 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Treat hemorrhoids only when the patient complains of them. The old adage that it is hard to make an asymptomatic patient better applies here. No matter how bad the hemorrhoids look to the practitioner, they should not be treated unless they bother the patient.

RELEVANT ANATOMY

Section 4 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg, arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz muscle), and connective tissue lined by the normal epithelium of the anal canal. Hemorrhoids are present in utero and persist through normal adult life. Evidence indicates that hemorrhoidal bleeding is arterial and not venous. This evidence is supported by the bright red color and arterial pH of the blood.

Hemorrhoids are categorized into internal and external hemorrhoids. These categories are anatomically separated by the dentate (pectinate) line. External hemorrhoids are hemorrhoids covered by squamous epithelium, whereas internal hemorrhoids are lined with columnar epithelium. Similarly, external hemorrhoids are innervated by cutaneous nerves that supply the perianal area. These nerves include the pudendal nerve and sacral plexus. Internal hemorrhoids are not supplied by somatic sensory nerves and therefore cannot cause pain. At the level of the dentate line, internal hemorrhoids are anchored to the underlying muscle by the mucosal suspensory ligament.

Internal hemorrhoids have 3 main cushions. These cushions are situated in the left lateral, right posterior, and right anterior areas of the anal canal. Minor tufts can be found between the major cushions.

External hemorrhoidal veins are found circumferentially under the anoderm.  These veins can cause trouble anywhere around the circumference of the anus.

CONTRAINDICATIONS

Section 5 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Care must be taken to ensure that symptoms are not caused by other perianal diseases (eg, fissure, fistula, infectious, inflammatory bowel, parasites). Obviously, treating hemorrhoids will not improve these conditions.  Frequently, a thorough history can eliminate the above conditions. 

Inflammatory bowel diseases (eg, ulcerative colitis, Crohn disease) need to be ruled out as causes of symptoms. 

HIV and other immune suppressive diseases can alter treatment plans as well.

WORKUP

Section 6 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Lab Studies

• Hematocrit testing is suggested if excessive bleeding with concomitant anemia is suspected.
• Coagulation studies are indicated if the history and physical examination suggest coagulopathy.

Imaging Studies

• Barium enema study or virtual colonoscopy is suggested if proximal colonic and intestinal diseases must be excluded and if endoscopy is not helpful.

Diagnostic Procedures

• Examination begins with inspection and examination of the entire perianal area. Warn the patient before any probing or poking. Patient apprehension is great prior to any anal examination. Go to great lengths to reassure the patient. Gentle spreading of the buttocks allows easy visualization of most of the anoderm; this includes the distal anal canal. Anal fissures and perianal dermatitis (pruritus ani) are easily visible without internal probing. Note the location and size of skin tags and the presence of thromboses. Normal corrugation of the anoderm and a normal anal wink with stimulation confirms intact sensation. Digital examination of the anal canal can identify any indurated or ulcerated areas. Be sure to palpate the prostate in all men. Because internal hemorrhoids are soft vascular structures, they are usually not palpable.
• Anoscopy is mandatory for viewing internal hemorrhoids. The anoscope should be a side-viewing scope. When angled well by the examiner, the side-viewing anoscope allows the soft hemorrhoidal tufts to fill the beveled end of the scope and to be appropriately evaluated. Prolapse can be observed when the patient performs a Valsalva maneuver. Flexible sigmoidoscopy is performed to exclude proximal disease. Having a patient strain while sitting on a toilet may reproduce prolapse most accurately. Examining patients while they sit on a toilet can be very helpful in indeterminate cases. Colonoscopy, virtual colonoscopy, and barium enema are reserved for cases of bleeding without an identified anal source. These symptoms are not attributable to hemorrhoids and are considered non–outlet-type bleeding.

Histologic Findings

Routine histologic examination of hemorrhoidal tissue is usually unrewarding, especially if it is grossly examined by an experienced anorectal surgeon. Any suspicious tissue must be sent for microscopic evaluation. External hemorrhoids are classified by underlying pathology and symptoms, which include thrombosed veins, bleeding from eroded blood clots, and skin tags causing hygiene problems.

Staging

Internal hemorrhoids are grouped into 4 stages, as follows: 

• Stage I - Internal hemorrhoids that bleed 
• Stage II – Internal hemorrhoids that cause bleeding and prolapse with straining but return to their resting point by themselves
• Stage III - Internal hemorrhoids that bleed and prolapse with straining and require manual effort for replacement into the anal canal 
• Stage IV - Internal hemorrhoids that do not return into the anal canal and, thus, are constantly outside

TREATMENT

Section 7 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Medical therapy

Treatment is divided by the cause of symptom into internal and external treatments. Internal hemorrhoids do not have cutaneous innervation and, thus, can be destroyed without anesthetic. Internal hemorrhoids are classified by symptom and are grouped into 4 stages, as described in the Staging section. 

Because most physicians believe that straining and a low-fiber diet cause hemorrhoidal disease, conservative treatment includes increasing fiber and liquid intake and retraining in toilet habit. Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, first-line treatment of all first- and second-degree (and many third- and fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation.

Psyllium seed significantly decreases bleeding and pain compared with placebo. The average American diet consists of 8-15 grams of fiber per day. A high-fiber diet includes more than 25 grams of fiber per day. Psyllium seed (Metamucil) and methylcellulose (Citrucel) are the most commonly used supplements. Many hemorrhoid symptoms resolve when only when they are treated with dietary alterations, including increased fiber and adding fiber supplements.

Antidiarrheal agents are sometimes required in patients with symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids.

Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, have a small role in the treatment of hemorrhoidal symptoms. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. The author rarely recommends typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. Submucosal veins do not get smaller with anti-inflammatory medications.

Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. The author does not suggest mechanisms such as the sitz bath for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role with older patients and with immobile patients who cannot routinely get in and out of a bathtub.

Many patients see improvement or complete resolution of their symptoms with the above conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after one month of conservative therapy. Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids. Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. A wise, old professor once said, "You can't make an asymptomatic patient feel better." Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome.

Treatment of the underlying disease often relieves anal symptoms. Patients with ulcerative colitis can tolerate aggressive surgery if needed. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere.

Pregnancy is associated with many anorectal complaints. Treatment is directed at symptoms. Nonoperative treatment or office thrombectomy usually relieves complaints. Operative hemorrhoidectomy is safe in pregnant women.

HIV and anal disease often occur together. Again, conservative therapy is suggested, especially if immunosuppression is evident. Poor healing occurs with low CD4 counts, especially those less than 200 cells/mm³.

Numerous methods to destroy internal hemorrhoids are available; they include rubber band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, carbon dioxide freezing, Lord dilatation, stapled hemorrhoidectomy, and surgical resection. All of these methods (except stapled hemorrhoidectomy and surgical resection) are considered nonoperative treatments and should be the first-line treatment of all first- and second-degree internal hemorrhoids that do not respond to conservative therapy.

With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively. All nonoperative treatments have approximately similar efficiency when used by an experienced clinician. Rubber band ligation is most common in the United States because it is the most commonly taught method in training programs. Blaidsell and Baron described and refined ligation therapy.^{1, 2} Lord dilatation is seldom used in the United States, and many colorectal surgeons condemn its use because it is essentially an uncontrolled disruption of the sphincter mechanism.

Sclerotherapy can provide adequate treatment of early internal hemorrhoids. Cryotherapy and sclerotherapy are infrequently used today. Most experienced surgeons use 1 or 2 techniques exclusively.

Symptoms have historically been treated with dietary modifications, incantations, voodoo, quackery, and application of a hot poker. Molten lead has also been described as a treatment. The adverse effects of these treatments have a direct relationship to whether patients relay persistent or recurrent complaints to the physician or return for further treatment.

Surgical therapy

Operative resection is reserved for patients with third- and fourth-degree hemorrhoids, patients who fail nonoperative therapy, and patients who also have significant symptoms from external hemorrhoids or skin tags. Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, one prospective study found no difference between scalpel and laser hemorrhoidectomy. The reader is referred to appropriate textbooks to see descriptions of techniques used.^{3, 4}

External hemorrhoids generally elicit symptoms due to acute thrombosis, recurrent thromboses, or hygiene problems. Manage acute thromboses and recurrent thromboses in a similar fashion. Identify the offending vascular cluster. In the office or clinical setting, inject local anesthetic, and then perform excision of the overlying skin and underlying veins.

Enucleation of the thrombosis alone can result in recurrence of the hemorrhoid at the same spot in the future. Excision of the underlying vein completely prevents this embarrassing event. Electrocoagulation or topical astringent (Monsel's solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone.

Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), has recently become prominent. It was first described in 1997-1998. During PPH, a specially designed circular stapler with smaller staples is used. The technique involves placing a suture in the mucosa and submucosal layers circumferentially approximately 3-4 cm above the dentate line. The stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a circular staple line above the dentate line. This results in resection of excessive internal hemorrhoidal tissue, pexy of the internal hemorrhoidal tissue left behind and interruption of the blood supply from above. It can be done as an outpatient, using local anesthesia with intravenous (IV) sedation.

PPH is mainly used to treat internal hemorrhoids not amenable to conservative and nonoperative therapies. Narcotic use and recovery is significantly decreased compared with conventional operative hemorrhoid surgery.

PPH does not directly affect the external tissue. Reports have described shrinking of external hemorrhoidal tissue after PPH, probably from decreased blood flow. PPH combined with judicial excision of occasional skin tags is also reported, with good results.

Patients receiving PPH seem to have less severe pain for a shorter duration compared with conventional surgery. The use of PPH is suggested in patients with large internal hemorrhoids and minimal external component. This procedure can be done in an outpatient setting with local anesthesia, similar to the protocol used for conventional hemorrhoid surgery.  The author has incorporated PPH into practice more frequently with excellent results.

Operative resection is reserved for patients with hygiene trouble caused by large skin tags, a history of multiple external thromboses, or internal hemorrhoid trouble. Perform the operation in the outpatient setting. Proper anesthetic care (especially if local anesthesia with supplementary IV sedation), attention to perioperative fluid restriction, and careful postoperative instructions can ease the patient's recovery. Operative technique can be found in any colorectal surgical textbook.

Patients with ulcerative colitis can tolerate aggressive surgery if needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women.

Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is large internal hemorrhoid prolapse. The sphincter mechanism squeezes, incarcerating the internal hemorrhoids and strangulates them. The resulting spasm causes edema and, occasionally, thrombosis of the external hemorrhoids. The resulting pain and swelling is dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported.

Preoperative details

Hemorrhoid surgery can usually be performed using local anesthesia with IV sedation. Regional or general anesthetic techniques are also used. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas.

Intraoperative details

The reader is referred to detailed surgical textbooks for specific details.^{3, 4}

Postoperative details

Attention to regular and soft bowel movements is important. Bulk agents (eg, psyllium seed) and oral fluids are important. Bathing in tubs for comfort and hygiene is part of the routine. Judicious narcotic administration relieves pain.

Follow-up

Monitor patients at regular intervals until they are healed and have no symptoms.

COMPLICATIONS

Section 8 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Well-trained surgeons should experience complications in fewer than 5% of cases. Complications include stenosis, bleeding, infection, recurrence, nonhealing wounds, and fistula formation. Urinary retention is directly related to the anesthetic technique used and to the perioperative fluids administered. Limiting fluids and the routine use of local anesthesia can reduce urinary retention to less than 5%.

OUTCOME AND PROGNOSIS

Section 9 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

Accurately classifying a patient's symptoms and the relation of the symptoms to internal and external hemorrhoids is important. Internal hemorrhoid symptoms often respond to increasing fiber and liquid intake and avoiding straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms persisting despite conservative therapy.

PPH is an excellent alternative for treating internal hemorrhoids not amenable to conservative or nonoperative approaches. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with PPH and skin tag excision. Operative resection is sometimes required to control symptoms of internal hemorrhoids.

External hemorrhoidal symptoms are generally divided into acute thrombosis problems and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), while operative resection is reserved for the latter. Remember, therapy is directed solely at the symptoms, not aesthetics.

When performed well, operative hemorrhoidectomy should have a 2-5% recurrence rate. Nonoperative techniques, such as rubber band ligation, produce recurrence rates of 30-50% within 5-10 years. However, these recurrences can usually be treated with further nonoperative treatments. Long-term results from PPH are unavailable at this time.

FUTURE AND CONTROVERSIES

Section 10 of 11  

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

The major controversies regarding the treatment of hemorrhoids center on the indications for treatment and the choice of operative versus nonoperative therapy. Most experienced surgeons are using office-based nonoperative therapies and relying less on operative hemorrhoidectomy than they were before. In the United States, rubber band ligation (compared with injection sclerotherapy) is the mainstay of conservative treatment. PPH provides an excellent alternative to operative hemorrhoidectomy for patients with minimal external disease and large internal hemorrhoids and is gaining increasing favor in the United States.

REFERENCES

Section 11 of 11

• Authors and Editors
• Introduction
• Indications
• Relevant Anatomy
• Contraindications
• Workup
• Treatment
• Complications
• Outcome And Prognosis
• Future And Controversies
• References

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Article Last Updated: Nov 20, 2007