Hemorrhoids: Diagnosis and Treatment Options

 

Am Fam Physician. 2018 Feb 1;97(3):172-179.

  Patient information: A handout on hemorrhoids is available.

Author disclosure: No relevant financial affiliations.

Many Americans between 45 and 65 years of age experience hemorrhoids. Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures; therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue; however, this procedure has several potential postoperative complications. Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly. Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms.

Hemorrhoids develop when the venous drainage of the anus is altered, causing the venous plexus and connecting tissue to dilate, creating an outgrowth of anal mucosa from the rectal wall. However, the exact pathophysiology is unknown. Hemorrhoids occur above or below the dentate line where the proximal columnar transitions to the distal squamous epithelium (Figure 11). The anus is approximately 4 cm long in adults, with the dentate line located roughly at the midpoint.2 Hemorrhoids developing above the dentate line are internal. They are painless because they are viscerally innervated. External hemorrhoids develop below the dentate line and can become painful when swollen. The extent of prolapse of internal hemorrhoids can be graded on a scale from I to IV, which guides effective treatment (Figure 2). This grading system is incomplete, however, because it focuses exclusively on the extent of prolapse and does not consider other clinical factors, such as size and number of hemorrhoids, amount of pain and bleeding, and patient comorbidities and preferences.3

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SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Increasing fiber intake is an effective first-line, non-surgical treatment for hemorrhoids.

A

7, 912

Most patients who undergo excision of thrombosed hemorrhoids within two to three days of symptom onset achieve symptom relief.

B

7, 10, 1922

Rubber band ligation is considered the preferred choice in the office-based treatment of grades I to III hemorrhoids because of effectiveness compared with other office-based procedures.

A

7, 10, 21, 23, 37

Excisional (conventional) hemorrhoidectomy is effective for the treatment of grade III or IV, recurrent, or highly symptomatic hemorrhoids.

A

7, 9, 10, 21, 23, 3235

The use of Ligasure during conventional hemorrhoidectomy leads to decreased pain in the immediate postoperative period.

A

32, 34

Compared with conventional hemorrhoidectomy, stapled hemorrhoidopexy results in more frequent recurrence of symptoms and prolapse.

A

10, 3537

Hemorrhoidal artery ligation is an emerging therapy with early outcomes similar to conventional hemorrhoidectomy for grade II or III hemorrhoids.

C

28, 37


A = consistent, good-quality patient-oriented evidence; B = inconsistent or limited-quality patient-oriented evidence; C = consensus, disease-oriented evidence, usual practice, expert opinion, or case series. For information about the SORT evidence rating system, go to http://www.aafp.org/afpsort.

SORT: KEY RECOMMENDATIONS FOR PRACTICE

Clinical recommendationEvidence ratingReferences

Increasing fiber intake is an effective first-line, non-surgical treatment for hemorrhoids.

A

7, 912

Most patients who undergo excision of thrombosed hemorrhoids within two to three days of symptom onset achieve symptom relief.

B

7, 10, 1922

Rubber band ligation is considered the preferred choice in the office-based treatment of grades I to III hemorrhoids because of effectiveness compared with other office-based pr

The Authors

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TIMOTHY MOTT, MD, FAAFP, is Family Medicine Specialty Leader to the Surgeon General of the U.S. Navy at Naval Hospital Pensacola (Fla.). Dr. Mott is also an associate professor of family medicine at the Uniformed Services University of the Health Sciences in Bethesda, Md....

KELLY LATIMER, MD, MPH, FAAFP, is a family physician at U.S. Naval Hospital Sigonella, Catania, Italy. Dr. Latimer is also an associate professor of family medicine at the Uniformed Services University of the Health Sciences.

CHAD EDWARDS, MD, FACS, is a general/acute care/trauma surgeon at Hamilton Medical Center in Dalton, Ga. At the time the article was submitted, Dr. Edwards was a general surgeon at Naval Hospital Pensacola and an assistant professor of surgery at the Uniformed Services University of the Health Sciences.

Address correspondence to Timothy Mott, MD, FAAFP, Naval Hospital Pensacola Department of Family Medicine, 6000 West Hwy 98, Pensacola, FL 32512. Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.

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