Management of Hemorrhoids by
Colon Rectal Surgical Associates

Hemorrhoids have plagued human beings throughout history, perhaps beginning when we first assumed an upright posture. In our practice individuals with varying rectal complaints seek medical attention complaining of "hemorrhoids". The biggest complaint usually involves bleeding, while others include, pain, mucus leakage, anal itching or irritation. Only a minor percentage of these complaints are actually due to hemorrhoids. It is essential therefore, that treatment for hemorrhoids is only undertaken if they are truly symptomatic. The mere presence of hemorrhoids is not an indication for any therapeutic intervention. Two types of hemorrhoids exist: a) External, just outside the anal canal, usually asymptomatic, but can become swollen and painful and b) Internal located inside the anal canal. Patients more often see us for internal hemorrhoidal symptoms, and these are relatively specific. Patients either present with bright red blood per rectum or a prolapsing anal mass.

Many myths exist regarding the cause of symptomatic internal hemorrhoids. The development of hemorrhoids has been attributed to prolonged periods of driving, sitting on cold seats or benches, eating spicy foods, and doing manual labor. These activities are rarely the cause of anal problems. Additionally, internal hemorrhoids are not similar to varicose veins, but are cushions of tissue with arteries and veins.

The standard classification consists of four Grades, which describe what is happening to the internal hemorrhoids. Grade 1 hemorrhoids are those that cause bleeding, but do not have redundant or prolapsing tissue. Grade 2 hemorrhoids are those that cause bleeding, and in addition, prolapse outside of the anus at the time of bowel movement. The hemorrhoidal tissue, however, spontaneously returns back into the anal canal after a bowel movement. Grade 3 hemorrhoids also bleed and prolapse; however, these hemorrhoids will remain outside the anal canal until they are manually pushed back inside. Grade 4 hemorrhoids present with the internal hemorrhoids sitting outside the anus, and will re-prolapse even when pushed back inside. All Grades can have external skin tags associated with them, but typically as the Grade gets higher more tagging is associated.

After confirming that the symptoms are indeed due to Hemorrhoids (and not cancer or other ano-rectal problems), the majority of our patients (80-85%) are then managed in office without a surgical procedure, thereby not losing time from work. Medical management for Grade 1 hemorrhoids is one method of treatment. Another method Infrared Coagulation is used for both Grade 1 and occasionally Grade 2 hemorrhoids. We find in our practice that this technique is not as effective as Rubber band ligation (an office procedure to tie off the hemorrhoids) for most Grade 2 hemorrhoids because it will require a greater number of treatments and takes longer to administer each treatment. Rubber band ligation is the most frequent technique we use in our practice for symptomatic Grade 2 and Grade 3 hemorrhoids, taking only several seconds to perform, relatively painless with no lost time from work and usually requiring 1-3 treatments.

For patients who have very large Grade 3 hemorrhoids with a significant external component or Grade 4 hemorrhoids, our practice typically recommends a hemorrhoidectomy. This outpatient surgical procedure removes the redundant, prolapsing, internal hemorrhoidal tissue, as well as the external tag component. This procedure works very well, and in our experience, patient's symptoms resolve and their quality of life is significantly improved. Our patients have been very happy over the years with their long-term results, and generally experience no further hemorrhoidal problems in later life. Patients in the short term will experience discomfort following surgery, because the low rectum and anal canal are very sensitive areas. Depending upon the extensiveness of the surgery, a patient may miss 1 to 2 weeks of work. A common question regarding surgical management of hemorrhoids involves Laser treatment. Our practice has not used this for the past 10 years as our experience and that of others published in the literature show that Laser treatment for hemorrhoids actually leads to more post-operative pain and swelling then standard hemorrhoidectomy.

Recently, a more minimally invasive surgical approach has been introduced into the U.S., from Italy. The approach, called Procedure for Prolapse and Hemorrhoids (PPH), involves lifting up or resuspending the hemorrhoidal tissue to their original anatomic position, by cutting out a band of the prolapsed rectal mucosa, using a special circular stapling device. This procedure also reduces the blood flow to the internal and external hemorrhoids so that over the course of 4-6 weeks the hemorrhoids typically shrink in size relieving all pre operative symptoms. The PPH results in less pain than the traditional hemorrhoid surgery, because it is performed above the level where nerves end inside the anal canal. This procedure allows patients to be more active after their operative procedure, because of minimal pain and also allows the patient to return to work in only a few days. While short-term results are excellent, this procedure has not been around long enough to give any credible long-term follow-up.

All physician members of Colon Rectal Surgical Associates have experience with the PPH, and offer it as an alternative to those patients requiring hemorrhoidectomy who are clear candidates.

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