CME

Operative management of internal hemorrhoids

BODELL COMMUNICATIONS, INC. / PHOTOTAKE

Rochelle Paris Kline, PA-C

ABSTRACT
An estimated 50% of the population over age 50 years have
experienced hemorrhoidal symptoms at some point in their
lives. Improved surgical techniques for internal hemorrhoids can reduce postoperative pain and facilitate a quicker
recovery.
Keywords: painless rectal bleeding, prolapse, internal hemorrhoids, conventional hemorrhoidectomy, stapled hemorrhoidopexy, transanal hemorrhoidal dearterialization

Learning objectives
Describe the anatomy and causes of internal
hemorrhoids.
Identify clinical signs and symptoms of internal
hemorrhoids.
Describe treatment options and associated complications
for symptomatic hemorrhoids.

nternal 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 patients quality of life. Though the conventional hemorrhoidectomy is successful, newer techniques such as the stapled hemorrhoidopexy for prolapsed
hemorrhoids and transanal hemorrhoidal dearterialization
Rochelle Paris Kline practices in the Department of Surgical Oncology
at the University of Pittsburgh (Pa.) Medical Center. The author has
disclosed no potential conflicts of interest, financial or otherwise.
DOI: 10.1097/01.JAA.0000459809.87889.85
Copyright 2015 American Academy of Physician Assistants

FIGURE 1. Internal and external hemorrhoids

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
patients complaint.
The most common factors that contribute to symptomatic hemorrhoidal disease are:
irregular bowel movements (constipation or diarrhea)

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CME
TABLE 1.

Key points
An estimated 50% of the population over age 50 years
have experienced hemorrhoidal symptoms at some point
in their lives.
Because internal hemorrhoids are a normal part of
anatomy, treatment should be guided by the patients
symptoms.
Improved surgical techniques for internal hemorrhoids can
reduce postoperative pain and facilitate a quicker recovery.
Constipation and diarrhea are the primary cause of
hemorrhoidal disease, so adequate fiber and fluid intake
can improve symptoms.
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.

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
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Grading of internal hemorrhoids2

Grade 1painless bleeding, prolapse inside anal canal

Grade 2painless bleeding, prolapse outside anus with
bowel movement and spontaneously reduces
after bowel movement
Grade 3painless bleeding, prolapse outside anus with
bowel movement and needs to be manually
reduced
Grade 4painless or painful bleeding, prolapsed,
irreducible

When taking the patients history, include a detailed

review of the patients 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 patients 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
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Operative management of internal hemorrhoids

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
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

FIGURE 2. Prolapse of internal hemorrhoids before transanal

hemorrhoidal dearterialization

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

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CME

steroidal 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.

FIGURE 3. Examination after transanal hemorrhoidal

dearterialization

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 non30

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COMPLICATIONS
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
CONCLUSION
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. JAAPA
Earn Category I CME Credit by reading both CME articles in this issue,
reviewing the post-test, then taking the online test at http://cme.aapa.
org. Successful completion is defined as a cumulative score of at
least 70% correct. This material has been reviewed and is approved
for 1 hour of clinical Category I (Preapproved) CME credit by the
AAPA. The term of approval is for 1 year from the publication date of
February 2015.

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Operative management of internal hemorrhoids

4. Corman ML. Colon and Rectal Surgery. 3rd ed. Philadelphia,
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