Hemorrhoids: Types, Causes, and Treatment

Hemorrhoids Basics

• Hemorrhoids involve dilated portions of veins in the anal canal.
• Approximately 10 million people in the United States have hemorrhoids.
• About one third of those with hemorrhoids seek medical treatment annually.
• Shearing of the mucosa during defecation results in the sliding of structures in the anal canal wall like hemorrhoidal and vascular tissues.
• Increased pressure in hemorrhoidal tissue due to pregnancy can start hemorrhoids or make existing ones worse.

Types of Hemorrhoids

• Hemorrhoids above the internal sphincter are internal hemorrhoids; those outside the external sphincter are external hemorrhoids.
• Internal hemorrhoids are classified by their degree of prolapse:
  • First degree hemorrhoids do not prolapse or protrude into the anal canal.
  • Second degree hemorrhoids prolapse outside the anal canal during defecation but reduce spontaneously.
  • Third degree hemorrhoids prolapse to the extent that they require manual reduction.
  • Fourth degree hemorrhoids prolapse to the extent that they may not be reduced and are at risk for strangulation and thrombosis.

Symptoms and Treatment

• Hemorrhoids cause itching, pain, and are a common cause of bright red bleeding with defecation.
• External hemorrhoids can cause severe pain from the inflammation and edema caused by blood clotting.
  • This can lead to ischemia and eventual necrosis.
• Internal hemorrhoids usually aren't painful until they bleed or prolapse when they become enlarged.
• Relief can be achieved through good personal hygiene and avoiding excessive straining during defecation.
• A high-fiber diet with fruit and bran, along with increased fluid intake, can promote soft, bulky stools to prevent straining and prevent further issues.
• If diet changes are not enough, the addition of hydrophilic bulk-forming agents like psyllium may help.
• Other treatments include warm compresses, sitz baths, analgesic ointments and suppositories, and astringents like witch hazel which reduce engorgement.

Nonsurgical Treatment

• Nonsurgical treatments for hemorrhoids include infrared photocoagulation, bipolar diathermy, and laser therapy to affix the mucosa to the underlying muscle.
• Injection of sclerosing agents is effective for small, bleeding hemorrhoids
• Sclerotherapy involves injecting a sclerosing agent, like 5% phenol in saline, into the base of the hemorrhoid to cause blood vessel thrombosis and prevent prolapse.

Surgical Treatment

• A conservative surgical treatment for internal hemorrhoids is rubber band ligation.
  • The hemorrhoid is visualized through the anoscope, and its proximal portion is grasped with an instrument.
  • A small rubber band is slipped over the hemorrhoid, causing the tissue distal to the band to become necrotic and slough off.
  • Fibrosis occurs, drawing up the lower anal mucosa to adhere to the underlying muscle.
  • Drawbacks: Painful and can cause secondary hemorrhage and perianal infection.
• Stapled hemorrhoidopexy uses surgical staples to treat prolapsing hemorrhoids, and is associated with less postoperative pain and fewer complications.
• Hemorrhoidectomy or surgical excision may be performed if other methods are not successful.
  • Rectal sphincter is dilated digitally during surgery, and the hemorrhoids are removed with a clamp and cautery or are ligated and then excised.
  • After surgery, a small tube may be inserted through the sphincter to allow escape of flatus and blood.
  • Absorbable gelatin sponge or oxidized cellulose gauze may be placed over the anal wounds.