Office Treatment of Hemorrhoids

CHAPTER 106 Office Treatment of Hemorrhoids

Hemorrhoidal disease occurs in approximately 50% to 80% of the U.S. population. Although this disease is rarely fatal, it accounts for a great deal of human pain and suffering. Internal hemorrhoids are the most common cause of lower gastrointestinal (GI) bleeding. Nonetheless, it is imperative that the clinician confirm that bleeding is indeed originating from hemorrhoidal disease and not from a more proximal lesion. Occasionally, bleeding can be severe and is associated with anemia.

Most hemorrhoidal symptoms can be managed with medical therapies that include suppositories, topical agents, and fiber supplementation. Patients who fail medical therapies are appropriate candidates for in-office treatments of hemorrhoids. Only a minority of individuals requires definitive treatment for severe symptomatic hemorrhoids with a surgical hemorrhoidectomy or hemorrhoidopexy. A hemorrhoidectomy requires general or regional anesthesia and is associated with significant discomfort and loss of time from work and usual activities after surgery.

Rubber-band ligation is a time-tested and proven method for treating internal hemorrhoids. However, other approaches have been developed, with infrared photocoagulation (IRC) being used most frequently and, rarely, sclerotherapy. Direct-current (Ultroid) and radiofrequency (Bicap) techniques were described in the first edition of this text. Bicap is no longer available, and although Ultroid has recently been reintroduced to the market, the time required and the cost of the probes make it less likely to be used. Cryotherapy was also used in the past but not currently because of the availability of more cost-effective modalities. These therapies can be used selectively or in combination depending on the extent and severity of internal disease. Lasers have also been used for the treatment of internal disease. The treatment for external hemorrhoid disease has been unchanged for decades.

Two meta-analyses have been reported on the treatment of internal hemorrhoids. One concludes that band ligation is best, whereas the other supports IRC. In both instances, hemorrhoid symptoms resolved in 80% to 90% of properly selected cases.

The physician must know the anorectal anatomy (see Chapter 97, Clinical Anorectal Anatomy and Digital Examination) and must be able to perform a thorough anoscopic examination (see Chapter 98, Anoscopy) to appropriately assess and treat hemorrhoids.

After completion of any of these procedures, a medical program to regulate bowel habits should be implemented to prevent recurrence, which is as important as the surgical intervention itself.

Classifications and Symptoms

Hemorrhoids are enlarged arteriovenous vessels within fibrous tissue and are classified according to their origin either above or below the dentate (pectinate) line. Those developing from above the dentate line are internal hemorrhoids; those from below are external hemorrhoids. It should be clear that classification depends on origin, not on the location of the most distal portion of the hemorrhoid (Fig. 106-1).

Hemorrhoids above the dentate line—internal hemorrhoids—are covered by mucosa and do not have somatic sensory innervation. Thus, internal hemorrhoids are well suited for treatment in the office setting without anesthesia because they lack pain fibers. Those below the dentate line—external hemorrhoids—are covered by skin (anoderm) and are extremely sensitive. Treatment of external hemorrhoids requires some form of anesthesia. Mixed hemorrhoids refers to those vessels that originate right at the dentate line or to the presence of both internal and external hemorrhoidal tissue in continuity.

The anal canal can be divided into eight segments. With the patient lying in the left lateral decubitus position, they are as noted in Figure 106-2A. Internal hemorrhoids usually occur in three major positions based on the vascular architecture of the anal canal: the right anterior, right posterior, and left lateral positions (Fig. 106-2B). However, they can occur anywhere and even be circumferential. They also seem to “shift” with insertion of the anoscope, so absolute position is not that critical.

Internal hemorrhoids are also characterized by their size and degree of prolapse from grades I to IV, as noted in Table 106-1 and Figure 106-3. Symptoms of internal hemorrhoids include painless bleeding, prolapse, aching after defecation, and discharge. The key step in diagnosis and classification of internal hemorrhoids is anoscopic examination (see Chapter 98, Anoscopy). External hemorrhoids can form clots that are painful. Patients then present with a “painful lump.”

TABLE 106-1 Classification of Internal Hemorrhoids

Grade Description
I Small, do not prolapse
II Medium, prolapse and return spontaneously
III Large, prolapse but reduce manually
IV Largest, prolapse, not reducible

Hemorrhoidal skin tags are residual fibrotic masses of stretched skin. Their size can vary significantly. They are generally asymptomatic except for occasional pruritus. Most commonly, when larger, they can cause problems with hygiene.

Approximately 25% of internal hemorrhoid symptoms do not respond adequately to medical treatment and require further therapy. Most thrombosed external hemorrhoids require evacuation or excision to provide symptomatic relief.

Internal Hemorrhoids

Preprocedure Patient Preparation

NOTE: Only internal hemorrhoids are treated by IRC, banding, or sclerotherapy. Treatment of external hemorrhoids requires excision and is associated with pain, so at least local anesthetics are needed.


Rubber-band ligation (Barron or McGivney ligation), IRC, and sclerotherapy for internal hemorrhoids are discussed in the following sections. A summary of techniques and their indications is found in Table 106-2. The treatment of external hemorrhoids is covered later in this chapter and the treatment of perianal skin tags is dealt with separately in Chapter 108, Removal of Perianal Skin Tags (External Hemorrhoidal Skin Tags). Because of the associated discharge and poor patient acceptance, cryotherapy is not covered in this discussion.

Rubber-Band Ligation

Rubber-band ligation involves placing a rubber band around the base of an internal hemorrhoid. The ensnared tissue undergoes necrosis and sloughs. Rubber-band ligation is used for treatment of second- or third-degree bleeding or prolapsing internal hemorrhoids.


See Figure 106-6.

May 14, 2017 | Posted by in GENERAL & FAMILY MEDICINE | Comments Off on Office Treatment of Hemorrhoids

Full access? Get Clinical Tree

Get Clinical Tree app for offline access