Hemorrhoid Management Reviewed

A new study reviews the best options for evaluating and treating hemorrhoids and discusses the roles of established and innovative treatments.

Researchers from University Hospital, Queen's Medical Center (Nottingham, United Kingdom) identified randomized controlled trials and meta-analyses from the Medline database and The Cochrane library. Based on this evidence, they described the pathogenesis and causes of hemorrhoids, their classification based on their relationship to the dentate (pectinate) line, their presenting symptoms and evaluation, and their treatment. The researchers explained that inspection of the perineum, rectal examination, and anoscopy help differentiate hemorrhoids from other causes of anal canal bleeding, such as fissures, fistulas, tumor, polyps, anal warts, and rectal prolapse. This inspection is usually sufficient to visualize large external hemorrhoids.

Conservative treatment of hemorrhoids includes early use of fiber supplements, which has been associated with moderate relief of bleeding and overall symptoms. Useful lifestyle modifications may include better anal hygiene, sitz baths, greater fluid intake, relieving constipation, and avoiding straining, although these measures are not supported by good evidence.

Outpatient interventions include rubber band ligation, applied above the dentate line to minimize pain; nearly 80% of patients are satisfied with the short-term outcome of rubber band ligation, although common complications include pain and hemorrhage. An alternative to banding is injection sclerotherapy with use of a submucosal injection of 5% oily phenol into first- or second-degree hemorrhoids. This technique is not helpful for large, prolapsing hemorrhoids or for those with a large external component, and it has a high failure rate. Other outpatient techniques include infrared coagulation, which is less effective than banding and is not widely used. Limited evidence exists to support the use of cryosurgery, bipolar diathermy, and direct-current electrotherapy.

Surgical options include open and closed hemorrhoidectomy surgery, used only for large, symptomatic hemorrhoids refractory to outpatient treatment. In the open technique, the hemorrhoid is dissected out from the underlying anal sphincter complex with electrocauterization, laser surgery, the harmonic scalpel, or scissors; the vascular pedicle is controlled, and the mucosal defects are left open and are allowed to granulate by secondary intention. In the closed technique, the mucosal edges and skin are closed with a continuous suture, which promotes faster wound healing. Other surgical techniques include Doppler-guided hemorrhoidal artery ligation (which is relatively painless, has minimal morbidity, and a patient satisfaction rate of up to 60%), and stapled hemorrhoidopexy. The study was published in the February 16, 2008, issue of the British Medical journal (BMJ).

"Acutely thrombosed prolapsed hemorrhoids are very painful but most can be treated at home and usually settle within 10-14 days using ice packs, stool softeners, and analgesia,” concluded study authors Drs. Austin G. Acheson, M.D., and John H. Scholefield, M.D. "Topical calcium antagonists may help to relieve the pain. Emergency surgery may be needed in severe cases to remove the engorged hemorrhoid or debride necrotic tissue. This can resolve symptoms more rapidly but is often associated with severe morbidity.”

Hemorrhoids are a common condition that can be highly bothersome and even dangerous. All hemorrhoids are the result of the descent and prolapse of one of three fibrovascular cushions in the anal canal. Straining; inadequate fiber intake; prolonged time with bowel movements; and conditions that increase intra-abdominal pressure, such as pregnancy, contribute to the formation of hemorrhoids.


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University Hospital, Queen's Medical Center