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JAAPA Journal of the American Academy of Physician Assistants www.JAAPA.com 27

CME

Internal hemorrhoids are a normal part of human anatomy, but symptomatic hemorrhoids are one of the most common complaints encountered in a med-

ical offi ce. 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-fi ber 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 non-operative management of internal hemorrhoids with dietary fi ber and noncaffeinated fl uids can improve hem-orrhoidal symptoms.2

When conservative treatment fails, surgery is needed to improve the patient’s quality of life. Though the con-ventional hemorrhoidectomy is successful, newer tech-niques such as the stapled hemorrhoidopexy for prolapsed hemorrhoids and transanal hemorrhoidal dearterialization

have become more commonplace because they cause less postoperative pain and patients recover more quickly.

ANATOMY AND CAUSESInternal 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. Hemor-rhoids 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 rest-ing anal pressure comes from hemorrhoids.3 Recognizing that internal hemorrhoids are a normal anatomic fi nding is essential when deciding if surgery is the correct treatment plan.1,2 Surgical intervention is not supported for asymp-tomatic hemorrhoids; treatment should be targeted to the patient’s complaint.

The most common factors that contribute to symptom-atic hemorrhoidal disease are:• irregular bowel movements (constipation or diarrhea)

Operative management of internal hemorrhoidsRochelle Paris Kline, PA-C

Rochelle Paris Kline practices in the Department of Surgical Oncology at the University of Pittsburgh (Pa.) Medical Center. The author has disclosed no potential confl icts of interest, fi nancial or otherwise.

DOI: 10.1097/01.JAA.0000459809.87889.85

Copyright © 2015 American Academy of Physician Assistants

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

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FIGURE 1. Internal and external hemorrhoids

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.


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CME

• 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 strain-ing during labor, all of which cause engorgement of hemorrhoids• heredity, which is not a defi nitive 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 classifi ed into four grades depending on severity (Table 1).

HISTORY AND PHYSICAL EXAMINATIONPainless 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 dif-fi culty 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, burn-ing, or pruritus, and keep in mind that the pain may have another source, such as an anal fi ssure.

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

When taking the patient’s history, include a detailed review of the patient’s bowel habits: frequency, stool con-sistency, and whether the patient strains at stool. Ask the patient about intake of noncaffeinated fl uid, fi ber, 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, remov-ing them may worsen a patient’s incontinence.

The differential diagnosis for internal hemorrhoidal disease includes anal fi ssure, abscess, fi stula, cancer, papilla, or condyloma, anorectal polyp, colorectal cancer, procti-tis, 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 recom-mended for patients with rectal bleeding who are age 40 years or older and have no identifi able 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 inspec-tion of the external and internal anoderm. External hemorrhoids consist of squamous epithelium that is modifi ed and does not include hair follicles. Thus, they are covered with skin. Because external hemorrhoids arise below the dentate line and are sensate, external hemor-rhoidal 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 hemor-rhoids 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 loca-tions 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 exam-ination. Rectal prolapse will appear as circumferential concentric rings. Hemorrhoidal prolapse appears as radial

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 patient’s 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.

• Grade 1— painless bleeding, prolapse inside anal canal

• Grade 2— painless bleeding, prolapse outside anus with bowel movement and spontaneously reduces after bowel movement

• Grade 3— painless bleeding, prolapse outside anus with bowel movement and needs to be manually reduced

• Grade 4— painless or painful bleeding, prolapsed, irreducible

TABLE 1. Grading of internal hemorrhoids2


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 fl exible sigmoidoscopy are recommended to evaluate for rectal masses or proctitis.

CONSERVATIVE TREATMENT OPTIONSConstipation and diarrhea are the primary cause of hem-orrhoidal disease, so adequate fi ber and fl uid intake can improve symptoms. Advise patients to increase dietary fi ber to 25 to 30 g per day, to use over-the-counter (OTC) fi ber supplements and osmotic laxatives as necessary, and drink 6 to 8 cups of noncaffeinated fl uids. 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 bath-room (prolonged sitting causes further engorgement of hemorrhoids). Numerous prescription and OTC topical preparations, including corticosteroid creams, supposi-tories, 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 interven-tion. 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. Sclero-therapy consists of injecting a sclerosing agent such as phenol into the apex of the internal hemorrhoid to induce fi brosis and scarring. Infrared coagulation is the direct application of infrared waves to cause tissue necrosis and scarring. These offi ce-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 abil-ity to fully band the entire hemorrhoid. Sclerotherapy and infrared coagulation can treat painless rectal bleed-ing, but do not treat hemorrhoidal prolapse.1,2

CONVENTIONAL HEMORRHOIDECTOMYConventional 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

Recent studies suggest that bipolar energy is quicker and causes patients less postoperative pain.1,6

Patients most likely will need opioids to manage post-operative pain. This unfortunately leads to constipation that only exacerbates discomfort. Encourage patients to take fi ber supplements or osmotic laxatives and drink 6 to 8 cups of noncaffeinated fl uid daily to make bowel movements easier.

Hemorrhoidectomy has been shown to be highly effective for grade 3 hemorrhoids compared to offi ce 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 HEMORRHOIDSFor patients with grades 2 through 4 hemorrhoids, stapled hemorrhoidopexy has been found equally effective as conventional hemorrhoidectomy.8-10 The stapled hemor-rhoidopexy was introduced in 1998, and uses a circular stapling device that excises prolapsed hemorrhoidal tissue.2,8 Residual tissue is fi xed 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

FIGURE 2. Prolapse of internal hemorrhoids before transanal hemorrhoidal dearterialization


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CME

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

Specifi c postoperative complications related to the stapling mechanism include rectal perforation, rectovaginal fi stula, 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 DEARTERIALIZATIONA new approach introduced in 1995, transanal hemor-rhoidal 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 non-

steroidal anti-infl ammatory 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.

COMPLICATIONSSurgery for internal hemorrhoids can cause bleeding, infec-tion, 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 sep-ticemia if not recognized early and treated with IV anti-biotics.19 Urinary retention usually resolves within 72 hours once initial postoperative edema subsides, and can be treated with temporary catheterization.20 Fecal incon-tinence can be treated initially with bulk-forming agents such as oral fi ber supplements; the anus has greater control with formed stool compared with loose stool.2 Anal stenosis can be treated with anal dilations in the offi ce or OR.20

CONCLUSIONBecause hemorrhoids are a normal part of our anatomy, their presence does not always warrant treatment. As with all disease processes, the history and physical exam-ination is imperative to guiding treatment and determin-ing 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 defi ned 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.

REFERENCES 1. Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters

for the management of hemorrhoids (revised 2010). Dis Colon Rectum. 2011;54(9):1059-1064.

2. Beck DE, Roberts PL, Rombeau JL, et al. The ASCRS Manual of Colon and Rectal Surgery. New York, NY: Springer; 2009:225-257.

3. Farouk R, Duthie GS, MacGregor AB, Bartolo DC. Sustained internal sphincter hypertonia in patients with chronic anal fi s-sure. Dis Colon Rectum. 1994;37(5):424-429.

FIGURE 3. Examination after transanal hemorrhoidal dearterialization


Operative management of internal hemorrhoids


4. Corman ML. Colon and Rectal Surgery. 3rd ed. Philadelphia, PA: J.B. Lippincott Co.; 1993.

5. Ho YH, Buettner PG. Open compared with closed haemorrhoid-ectomy: meta-analysis of randomized controlled trials. Tech Colo-proctol. 2007;11(2):135-143. http://www.unboundmedicine.com/medline/citation/17510742/Open_compared_with_closed_ haemorrhoidectomy:_meta_analysis_of_randomized_controlled_trials_. Accessed September 16, 2014.

6. Nienhuijs S, de Hingh I. Conventional versus LigaSure hemor-rhoidectomy for patients with symptomatic hemorrhoids. Cochrane Database Syst Rev. 2009;(1):CD006761.

7. MacRae HM, McLeod RS. Comparison of hemorrhoidal treat-ment modalities. A meta-analysis. Dis Colon Rectum. 1995;38(7):687-694.

8. Ommer A, Hinrichs J, Möllenberg H, et al. Long-term results after stapled hemorrhoidopexy: a prospective study with a 6-year follow-up. Dis Colon Rectum. 2011;54(5):601-608.

9. Nisar PJ, Acheson AG, Neal KR, Scholefi eld JH. Stapled hemor-rhoidopexy compared with conventional hemorrhoidectomy: systematic review of randomized, controlled trials. Dis Colon Rectum. 2004;47(11):1837-1845.

10. Manfredelli S, Montalto G, Leonetti G, et al. Conventional (CH) vs. stapled hemorrhoidectomy (SH) in surgical treatment of hemor-rhoids. Ten years experience. Ann Ital Chir. 2012;83(2):129-134.

11. Ribaric G, Kofl er J, Jayne DG. Stapled hemorrhoidopexy, an innovative surgical procedure for hemorrhoidal prolapse: cost-utility analysis. Croat Med J. 2011;52(4):497-504.

12. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled hemor-rhoidopexy is associated with a higher long-term recurrence rate of internal hemorrhoids compared with conventional excisional hemorrhoid surgery. Dis Colon Rectum. 2007;50(9):1297-1305.

13. Pescatori M, Gagliardi G. Postoperative complications after pro-cedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures. Tech Coloproctol. 2008;12(1):7-19.

14. Tjandra JJ, Chan MK. Systematic review on the procedure for prolapse and hemorrhoids (stapled hemorrhoidopexy). Dis Colon Rectum. 2007;50(6):878-892.

15. Morinaga K, Hasuda K, Ikeda T. A novel therapy for internal hemorrhoids: ligation of the hemorrhoidal artery with a newly devised instrument (Moricorn) in conjunction with a Doppler fl owmeter. Am J Gastroenterol. 1995;90(4):610-613.

16. Infantino A, Bellomo R, Dal Monte PP, et al. Transanal haemorrhoidal artery echodoppler ligation and anopexy (THD) is effective for II and III degree haemorrhoids: a —prospective multicentric study. Colorectal Dis. 2010;12(8):804-809.

17. Giordano P, Overton J, Madeddu F, et al. Transanal hemor-rhoidal dearterialization: a systematic review. Dis Colon Rectum. 2009;52(9):1665-1671.

18. Ratto C, Donisi L, Parello A, et al. Evaluation of transanal hemorrhoidal dearterialization as a minimally invasive therapeu-tic approach to hemorrhoids. Dis Colon Rectum. 2010;53(5):803-811.

19. Karadeniz Cakmak G, Irkorucu O, Ucan BH, Karakaya K. Fournier’s gangrene after open hemorrhoidectomy without a predisposing factor: report of a case and review of the literature. Case Rep Gastroenterol. 2009;3(2):147-155.

20. Koller SE. Hemorrhoidectomy. http://emedicine.medscape.com/article/1829854-overview#a17. Accessed September 16, 2014.


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