Internal hemorrhoids are a normal part of human anatomy, but symptomatic hemorrhoids are one of the most common complaints encountered in a medical office. Painless rectal bleeding and prolapsed tissue are the most common internal hemorrhoidal symptoms, can occur at any age, and affect both sexes. An estimated 50% of the population over age 50 years have experienced hemorrhoidal symptoms at some point in their lives.1 The rich, low-fiber Western diet leads not only to an increase in heart disease and diabetes but also poor bowel habits such as constipation, one of the most common causes of hemorrhoidal disease.1,2 Conservative treatment or nonoperative management of internal hemorrhoids with dietary fiber and noncaffeinated fluids can improve hemorrhoidal symptoms.2
When conservative treatment fails, surgery is needed to improve the patient's quality of life. Though the conventional hemorrhoidectomy is successful, newer techniques such as the stapled hemorrhoidopexy for prolapsed hemorrhoids and transanal hemorrhoidal dearterialization have become more commonplace because they cause less postoperative pain and patients recover more quickly.
ANATOMY AND CAUSES
Internal hemorrhoids are normal vascular cushions in the anal canal proximal to the dentate line (Figure 1). They are located in the submucosa, and are insensate. Bleeding from internal hemorrhoids typically is painless. Hemorrhoids are supplied arterially by the superior, middle, and inferior hemorrhoidal arteries, and drain venously via the middle rectal veins to the internal iliac veins. Coughing or straining leads the internal hemorrhoids to engorge with blood, helping maintain continence. The anal sphincter does not completely close at rest, and about 20% of resting anal pressure comes from hemorrhoids.3 Recognizing that internal hemorrhoids are a normal anatomic finding is essential when deciding if surgery is the correct treatment plan.1,2 Surgical intervention is not supported for asymptomatic hemorrhoids; treatment should be targeted to the patient's complaint.
The most common factors that contribute to symptomatic hemorrhoidal disease are:
- irregular bowel movements (constipation or diarrhea)
- prolonged straining during defecation, which causes abnormal distension and displacement of hemorrhoids, weakening the tissue over time and leading to prolapse
- pregnancy, which leads to increased circulating blood volume, impaired venous return, constipation, and straining during labor, all of which cause engorgement of hemorrhoids
- heredity, which is not a definitive cause, but suggestive. Weak-walled veins or decreased tissue strength may be hereditary, or hemorrhoidal disease may appear hereditary because families tend to have similar dietary habits.4
- aging, which causes laxity of the supporting soft-tissue structures of hemorrhoids, particularly the Trietz muscles.2
Prolapsed internal hemorrhoids are classified into four grades depending on severity (Table 1).
HISTORY AND PHYSICAL EXAMINATION
Painless bright red blood per rectum, mucus drainage, and a sensation of a lump or prolapsed tissue outside the anus with defecation are the most common complaints noted. Other complaints include anal pruritus; burning; and difficulty keeping the area clean, requiring protective pads or changing undergarments. Some patients complain of pain, although anatomically this does not make sense. Ask the patient to describe the pain in terms of discomfort, burning, or pruritus, and keep in mind that the pain may have another source, such as an anal fissure.
Document bleeding quantity and quality (bright red or melena); note whether the patient describes it as present on the toilet paper or dripping into the toilet. Ask the patient about any history of anemia or blood transfusions. Prolapse can be described as a mass at the anus noted with bowel movements or a sensation of incomplete emptying. Asking the patient whether the prolapse reduces spontaneously or needs to be reduced manually helps to guide treatment.2
When taking the patient's history, include a detailed review of the patient's bowel habits: frequency, stool consistency, and whether the patient strains at stool. Ask the patient about intake of noncaffeinated fluid, fiber, and food and dietary supplements.2 Ask if the patient has fecal incontinence; this may help determine if surgery is the best option. Because hemorrhoids provide continence, removing them may worsen a patient's incontinence.
The differential diagnosis for internal hemorrhoidal disease includes anal fissure, abscess, fistula, cancer, papilla, or condyloma, anorectal polyp, colorectal cancer, proctitis, and rectal prolapse. Patients who complain of rectal bleeding should be evaluated for a familial or hereditary risk of colorectal cancer. Patients who have a personal or family history of colorectal cancer or polyps require a more detailed colonic evaluation such as a colonoscopy to rule out polyps or neoplasia.1 Colonoscopy is recommended for patients with rectal bleeding who are age 40 years or older and have no identifiable source of bleeding, a positive family history of colorectal cancer, or a history suggesting a hereditary colorectal cancer syndrome.2
The physical examination should include careful inspection of the external and internal anoderm. External hemorrhoids consist of squamous epithelium that is modified and does not include hair follicles. Thus, they are covered with skin. Because external hemorrhoids arise below the dentate line and are sensate, external hemorrhoidal disease is characterized by pain and pruritus. Purplish or blue tissue may be noted externally. Internal hemorrhoids can be visualized externally (as red-tinged mucosal tissue) if they prolapse outside the anus.
Use a side-viewing anoscope to examine internal hemorrhoids and determine the degree of hemorrhoidal disease. Internal hemorrhoids are described in terms of their most common locations: right posterior, right anterior, and left lateral. Accessory hemorrhoidal tissue between these locations also is common.
To differentiate internal hemorrhoid prolapse from rectal prolapse, ask the patient to perform a Valsalva maneuver on the toilet, then perform an external examination. Rectal prolapse will appear as circumferential concentric rings. Hemorrhoidal prolapse appears as radial folds differentiating the separate hemorrhoids.2 A digital rectal examination is performed next to palpate for any masses, determine sphincter tone and any defects, and assess pain and bleeding. Proctoscopy and/or a flexible sigmoidoscopy are recommended to evaluate for rectal masses or proctitis.
CONSERVATIVE TREATMENT OPTIONS
Constipation and diarrhea are the primary cause of hemorrhoidal disease, so adequate fiber and fluid intake can improve symptoms. Advise patients to increase dietary fiber to 25 to 30 g per day, to use over-the-counter (OTC) fiber supplements and osmotic laxatives as necessary, and drink 6 to 8 cups of noncaffeinated fluids. Fiber should be started low and gradually increased so that patients do not develop adverse reactions such as abdominal bloating and cramping.1,2 Emphasize to patients to avoid straining on the toilet and not to read while in the bathroom (prolonged sitting causes further engorgement of hemorrhoids). Numerous prescription and OTC topical preparations, including corticosteroid creams, suppositories, and medicated wipes, are available for hemorrhoids, but no adequate evidence supports long-term success treating hemorrhoids with these products.2
When conservative management fails, office-based procedures may be considered before surgical intervention. In rubber band ligation, a rubber band is placed over redundant hemorrhoidal tissue, leading to necrosis and the hemorrhoid sloughing off in 5 to 7 days. Sclerotherapy consists of injecting a sclerosing agent such as phenol into the apex of the internal hemorrhoid to induce fibrosis and scarring. Infrared coagulation is the direct application of infrared waves to cause tissue necrosis and scarring. These office-based techniques are especially suited for patients who are not candidates for surgery. However, the success rate of these techniques is lower than that of surgery. For example, rubber band ligation may require multiple sessions because of the limited ability to fully band the entire hemorrhoid. Sclerotherapy and infrared coagulation can treat painless rectal bleeding, but do not treat hemorrhoidal prolapse.1,2
Conventional hemorrhoidectomy, the surgical excision of hemorrhoids, can be performed via an open or closed technique. The Milligan-Morgan or open technique excises hemorrhoids without suturing the defects closed. The sites heal by secondary intention in 4 to 8 weeks. In the Ferguson or closed technique, the defects are sutured closed after the hemorrhoids are excised.2 The closed method has been associated with faster wound healing, but studies have found no difference in the cure rate, postoperative pain, and infection rates.5
Scalpel, scissors, monopolar cauterization, or bipolar energy can be used for surgical excision of hemorrhoids.1 Recent studies suggest that bipolar energy is quicker and causes patients less postoperative pain.1,6
Patients most likely will need opioids to manage postoperative pain. This unfortunately leads to constipation that only exacerbates discomfort. Encourage patients to take fiber supplements or osmotic laxatives and drink 6 to 8 cups of noncaffeinated fluid daily to make bowel movements easier.
Hemorrhoidectomy has been shown to be highly effective for grade 3 hemorrhoids compared to office procedures. However, postoperative pain is a limiting factor.1,7 Patients may not be able to return to normal activities for 4 weeks postoperatively. This has led to alternative treatments described later.1,2,7
PROCEDURE FOR PROLAPSED HEMORRHOIDS
For patients with grades 2 through 4 hemorrhoids, stapled hemorrhoidopexy has been found equally effective as conventional hemorrhoidectomy.8-10 The stapled hemorrhoidopexy was introduced in 1998, and uses a circular stapling device that excises prolapsed hemorrhoidal tissue.2,8 Residual tissue is fixed to the internal anoderm, thus the term hemorrhoidopexy.11 Staples close the defect left from the excision.
Although hemorrhoidopexy is thought to cause less postoperative pain, leading to an earlier recovery, a 2007 Cochrane review of six randomized trials found no statistical differences in pain, pruritus, and urgency among hemorrhoidopexy patients compared with those who had had conventional hemorrhoidectomy. The studies reviewed greater than 1-year follow-up of 628 patients.12 In addition, the Cochrane review and another study published in 2011 found that patients who had hemorrhoidopexy had an elevated rate of long-term recurrence of hemorrhoids compared with patients who had conventional hemorrhoidectomy.8,12
Specific postoperative complications related to the stapling mechanism include rectal perforation, rectovaginal fistula, and staple line bleeding.2 A diverting temporary stoma may be required.13 In general, the rate of complications such as fever, fecal incontinence, urinary retention, and anal stenosis was the same.10,14
TRANSANAL HEMORRHOIDAL DEARTERIALIZATION
A new approach introduced in 1995, transanal hemorrhoidal dearterialization, uses an anoscope with ultrasound to identify the six branches of the superior rectal artery that are located above the dentate line. Ligation of the arteries takes place circumferentially. Anopexy of any redundant tissue can be performed intraoperatively by suturing the residual prolapse to the internal anoderm (Figures 2 and 3).15 No excision takes place, which is believed to lead to less postoperative pain.1 A study of 112 patients revealed that 72% of patients did not require postoperative analgesics. The remaining 28% used nonsteroidal anti-inflammatory drugs (NSAIDs) for fewer than 2 days.16
Hemorrhoidal prolapse recurs in about 10% of patients after transanal hemorrhoidal dearterialization.17,18 Other complications include bleeding, infection, and urinary retention.16 The appeal of dearterialization is decreased postoperative discomfort, shorter recovery time, and a quicker return to normal activities.
Surgery for internal hemorrhoids can cause bleeding, infection, urinary retention, fecal incontinence, or anal stenosis. Rates of complications are comparable regardless of the type of surgery.
Bleeding can be controlled with packing of the anal canal or suturing.2 Infection is rare, but can lead to septicemia if not recognized early and treated with IV antibiotics.19 Urinary retention usually resolves within 72 hours once initial postoperative edema subsides, and can be treated with temporary catheterization.20 Fecal incontinence can be treated initially with bulk-forming agents such as oral fiber supplements; the anus has greater control with formed stool compared with loose stool.2 Anal stenosis can be treated with anal dilations in the office or OR.20
Because hemorrhoids are a normal part of our anatomy, their presence does not always warrant treatment. As with all disease processes, the history and physical examination is imperative to guiding treatment and determining if further workup is warranted to rule out neoplasia or other disease processes. Newer operative techniques for internal hemorrhoids such as a hemorrhoidopexy or dearterialization may reduce postoperative pain and speed recovery. Overall complications of hemorrhoid surgery are comparable, but when they occur can be devastating.
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