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Management of Hemorrhoids

Hemorrhoids have plagued human beings throughout history, perhaps beginning when we first assumed an upright posture. In our practice individuals with varying rectal complaints seek medical attention complaining of "hemorrhoids". The biggest complaint usually involves bleeding, while others include, pain, mucus leakage, anal itching or irritation. Only a minor percentage of these complaints are actually due to hemorrhoids. It is essential therefore, that treatment for hemorrhoids is only undertaken if they are truly symptomatic. The mere presence of hemorrhoids is not an indication for any therapeutic intervention. Two types of hemorrhoids exist:
a) External, located outside the anal canal, usually asymptomatic, but can become swollen and painful
b) Internal located inside the anal canal.
Patients more often see us for internal hemorrhoidal symptoms, and these are relatively specific. Patients either present with bright red blood per rectum or a prolapsing anal mass.

Many myths exist regarding the cause of symptomatic internal hemorrhoids. The development of hemorrhoids has been attributed to prolonged periods of driving, sitting on cold seats or benches, eating spicy foods, and doing manual labor. These activities are rarely the cause of anal problems. Additionally, internal hemorrhoids are not similar to varicose veins, but are cushions of tissue with arteries and veins.

The standard classification of hemorrhoids consists of four Grades, which describe what is happening to the internal hemorrhoids.
• Grade 1 hemorrhoids can cause bleeding, but do not have redundant tissue.
• Grade 2 hemorrhoids can cause bleeding, and in addition, prolapse (slide) outside of the anus at the time of bowel movement. The hemorrhoidal tissue, however, spontaneously returns back into the anal canal after a bowel movement.
• Grade 3 hemorrhoids also bleed and prolapse; however, these hemorrhoids will remain outside the anal canal until they are manually pushed back inside.
• Grade 4 hemorrhoids present with the internal hemorrhoids sitting outside the anus, and will re-prolapse even when pushed back inside. All Grades can have external skin tags associated with them, but typically as the Grade gets higher more tagging is associated.

After confirming that the symptoms are indeed due to Hemorrhoids (and not cancer or other ano-rectal problems), the majority of our patients (80-85%) are then managed in office without a surgical procedure, thereby not losing time from work. Medical management for Grade 1 hemorrhoids is one method of treatment (high fiber diet, additions of psyllium products, increase fluids, remove reading materials from the bathroom). Other methods include, injection sclerotherapy, or Infrared Coagulation which can be used for Grade 1 and occasionally Grade 2 hemorrhoids. We find in our practice that Infrared Coagulation is not as effective as Rubber band ligation (an office procedure to tie off the hemorrhoids) for most Grade 2 hemorrhoids because it will require a greater number of treatments and takes longer to administer each treatment. Rubber band ligation is the most frequent technique used not only in our practice, but by Colon and Rectal Surgeons throughout the US for symptomatic Grade 2 and Grade 3 internal hemorrhoids, taking only several seconds to perform, relatively painless with no lost time from work and usually requiring 1-3 treatments.

For patients who have very large Grade 3 hemorrhoids with a significant external component or Grade 4 hemorrhoids, our practice typically recommends a hemorrhoidectomy. This outpatient surgical procedure removes the redundant, prolapsing, internal hemorrhoidal tissue, as well as the external tag component. This procedure works very well, and in our experience, patient's symptoms resolve and their quality of life is significantly improved. Our patients have been very happy over the years with their long-term results, and generally experience no further hemorrhoidal problems in later life. Patients in the short term will experience discomfort following surgery, because the low rectum and anal canal are very sensitive areas. A recent advancement in local anesthesia for post operative pain control, has been able to produce an almost complete absence of pain for the first 3 post operative days, the period of time patients experience their worst pain. This has shifted the paradigm for hemorroidal management, because the best procedure for treating large symptomatic hemorrhoids is becoming more acceptable to patients. A complaint in the past has been the amount of time someone will miss work, usually 1-2 weeks depending upon the amount of hemorrhoidal tissue removed during the procedure. With the use of this new long acting local anesthetic we are seeing patients going back to work within a week, similar to other techniques.

In the past decade additional procedures for treating large symptomatic hemorrhoids have been developed with a more minimally invasive surgical approach, with the idea of less post operative pain and an earlier return to work. The first technique, called Procedure for Prolapse and Hemorrhoids (PPH), involves lifting up or resuspending the hemorrhoidal tissue to their original anatomic position, by cutting out a band of the prolapsed rectal mucosa, using a special circular stapling device. This procedure also allegedly reduces the blood flow to the internal and external hemorrhoids so that over the course of 4-6 weeks the hemorrhoids typically shrink in size relieving all pre-operative symptoms. The PPH results in less pain than the traditional hemorrhoid surgery, because it is performed above the level where nerves end inside the anal canal. This would not be indicated in a patient with external tagging because it does not treat this. While short-term results had been promising, it has been losing favor with Colon and Rectal surgeons over the last several years because of post-operative problems. Additionally, the literature appears to indicate that there is a higher recurrence rate compared to standard hemorrhoidectomy.

Another newer procedure is the THD (Transanal Hemorrhoidal Dearterialization) whereby the feeder vessels to the hemorrhoids are tied off, using ultrasound guidance. This has early proponents, again for less post operative pain and earlier return to work, however, this technique adds about $500-700 cost to the surgery. Some follow up data to date show a 10-15% recurrence at 1 year for grade 3 hemorrhoids and up to a 60% recurrence for grade 4 hemorrhoids.