What are hemorrhoids? 

Patient information: Hemorrhoids [American College of Colon and Rectal Surgeons]

Patient education: Hemorrhoids (Beyond the Basics) [UpToDate]

• Hemorrhoids are a normal part of anorectal anatomy. They are blood vessels in the end of the rectum and at the anal verge. External hemorrhoids overlie the external anal sphincter (at the anal verge) and the internal hemorrhoids overlie the internal anal sphincter (inside the rectum). The hemorrhoids fill with blood and help maintain continence (avoid leaking stool). See images below.

• Anything that increases pressure in the abdomen, including prolonged straining, coughing, pregnancy, and an enlarged prostate requiring straining to urinate, can lead to abnormally large venous plexuses, which are what most people know as hemorrhoids. 

• Internal hemorrhoids are lined by the same tissue as the rest of the GI tract, which secretes mucus. External hemorrhoids are lined by the same tissue as the rest of the skin on our bodies.

Source: UpToDate Images: Internal and External Hemorrhoids

Symptoms

When hemorrhoids become abnormally large as a result of prolonged straining, typically from constipation, they can cause pain and bleeding. 

• Internal hemorrhoids- dull/ achy pain and bleeding with bowel movements. In addition, if internal hemorrhoids prolapse (move from inside the rectum out onto the perianal skin), which typically occurs with bowel movements, this can cause issues with perianal moisture, itching and skin irritation. This is caused by the mucus from the overlying tissue. Prolapsed hemorrhoids can sometimes reduce spontaneously (return to their normal location in the rectum) or might require manual reduction (might have to be pushed back in after having a bowel movement). If internal hemorrhoids 

• External hemorrhoids- bleeding with bowel movements. Acute pain can occur when an external hemorrhoid becomes thrombosed (acutely filled with blood clot→ overlying skin gets stretched→ severe pain).

What is conservative management for hemorrhoids?

• See “Anorectal Disease: How do I prevent anorectal disease?” Improving bowel habits is the first-line treatment for hemorrhoids. 

• See patient handouts below.

• Sitz baths- fill a tube with water as warm as you can tolerate, and soak your bottom after every bowel movement and at least 3 times per day.

• For itching: moisture in the perianal skin can cause itching. Improving bowel habits and gentle perianal skin hygiene can improve this. Zinc oxide can be used as a topical barrier twice daily.

• For protruding or swollen internal hemorrhoids: hold the hemorrhoid tissue with a Tucks pads (witch hazel) to decrease the swelling, allowing the hemorrhoid tissue to be reduced.

What is the operative management of hemorrhoids?

1. Acute thrombosis of external hemorrhoids- most patients will have resolution of symptoms with conservative management described above. However, if you present within the first 48-72 hours, the hemorrhoid can be excised. Incision and drainage alone is not recommended, given high rates of recurrence. If symptoms have been present for more than 72 hours, surgery is more likely to create more discomfort, and therefore it is typically avoided.

2. Large external hemorrhoids or mixed internal and external hemorrhoids with prolapse- typically managed with hemorrhoidectomy or hemorrhoidopexy.

3. Internal hemorrhoids- banding is the most common treatment. Other options include sclerotherapy and infrared coagulation.