Hemorrhoids

First chapter of Part II ("Anorectal Disease") of the ASCRS ingest, and the first dedicated hemorrhoids page in this wiki — Colorectal Anatomy & Embryology (Ch1) explicitly deferred full pathogenesis/treatment coverage here. Hemorrhoidal disease affects ~4% of the US population, accounts for over 3 million outpatient visits/year (>$770M cost), peak incidence age 45–65, equal sex frequency, more common in higher socioeconomic backgrounds and in whites — though true incidence is likely underestimated due to underreporting.

Anatomy and classification

Hemorrhoids are normal arteriovenous anatomic structures in the submucosal layer of the anal canal, not inherently pathologic (consistent with Colorectal Anatomy & Embryology's framing of them as present in all humans and functionally supporting continence). Three primary locations — left lateral, right anterior, right posterior — receive arterial inflow from terminal branches of the superior and middle hemorrhoidal arteries; venous outflow is via superior, middle, and inferior hemorrhoidal veins to the internal pudendal vein and IVC.

Classified as internal (proximal to the dentate line, overlying columnar mucosa) or external (distal, overlying anoderm); a mixed hemorrhoid complex contains both components.

Internal hemorrhoids are graded by degree of prolapse:

• Grade I — engorged but do not prolapse below the dentate line.
• Grade II — prolapse on Valsalva/defecation but spontaneously reduce.
• Grade III — prolapse and require manual reduction.
• Grade IV — prolapsed and not reducible.

Strangulated hemorrhoids are grade IV hemorrhoids that become edematous to the point of compromised blood supply, risking necrosis/gangrene. Thrombosed hemorrhoids are typically external, containing a clot under pressure, giving a rounded bluish appearance; distinct from anal skin tags (less engorged, redundant anoderm, often the residuum of a resolved thrombosed hemorrhoid).

Innervation: internal hemorrhoids have visceral innervation (sensitive to pressure, not pain/temperature); external hemorrhoids have somatic innervation (exquisitely pain/temperature sensitive) — the anatomic basis matches the dentate-line visceral/somatic transition already described in Colorectal Anatomy & Embryology. Hemorrhoids contribute up to 20% of baseline continence as a passive buttress against seepage, engorging further on Valsalva to potentiate this effect — a granular figure that sits alongside Anorectal Physiology's ~15% hemorrhoid- cushion contribution to resting anal tone (same phenomenon, not a contradiction) — with real implications for bowel function after hemorrhoid procedures in patients with marginal continence.

Pathogenesis

Only ~40% of patients with enlarged hemorrhoids are symptomatic. Straining (constipation-related or otherwise, e.g. weightlifters, patients with COPD/chronic cough) is felt to be the major contributor; the Western sitting commode (vs. a more natural squatting position) may also contribute. Impaired venous return (late pregnancy, pelvic outlet dysfunction) is associated with engorgement and tissue laxity. Genetic contribution is poorly understood beyond a GWAS signal; tissue-level associations include matrix metalloproteinases, VEGF, nitric oxide synthase, and neovascularization.

Clinical presentation

Internal hemorrhoids: painless bright-red bleeding with bowel movements (dripping/spraying), tissue protrusion/prolapse (intermittent or persistent, reducible or not), rectal pressure, mucus discharge, soiling. Pain is not typical of internal hemorrhoids unless prolapsed and strangulated — its presence should prompt reconsideration of the diagnosis (thrombosed external hemorrhoid, fissure, abscess). Hemorrhoids are rarely a cause of anemia despite patient-perceived bleeding severity.

External hemorrhoids: itching, irritation, perianal moisture, hygiene difficulty. Painless unless thrombosed, in which case a firm blue/purple tender or nontender nodule is visible/palpable.

History: extent/severity/duration of bleeding and prolapse, perianal hygiene, pain, fiber intake and bowel habits, acute bowel-habit changes (raising concern for IBD/neoplasm rather than hemorrhoids), anticoagulant use, fecal incontinence symptoms, prior anorectal surgery, obstetric history, pelvic radiation history.

Exam: inspection of gluteal cleft/perianal skin/perineum for external hemorrhoids, skin tags, condyloma, skin breakdown, fistulous openings, fissures, erythema, scars, masses, anal gape; digital rectal exam for other pathology and sphincter integrity; anoscopy to grade internal hemorrhoids; straining exam to assess prolapse and exclude full-thickness rectal prolapse. On exam, true rectal prolapse (concentric folds) must be distinguished from prolapsed hemorrhoids/mucosa (radial folds with intercushion grooves) — the same distinction Rectal Prolapse (Procidentia) makes from the prolapse side.

Malignancy exclusion: hemorrhoids are the most common cause of hematochezia, but rectal bleeding attributed to hemorrhoids is the most common missed opportunity to diagnose colorectal cancer. Any patient >45, with a bowel habit change, anemia, weight loss, or family history of CRC/Lynch syndrome needs colonoscopic evaluation rather than an assumed hemorrhoid diagnosis. Labs/imaging are not otherwise routinely required.

Treatment

Simple non-procedural strategies are first-line for non-emergent presentations, typically trialed 6–8 weeks before reassessment.

Medical management

• Stool habits: avoid prolonged toilet sitting/reading, avoid straining, use a foot stool to approximate squatting.
• Stool texture: soft, formed stool via 25–50 g/day fiber (psyllium, methylcellulose, calcium polycarbophil) plus adequate water intake (≥64 oz); probiotics/prebiotics as adjuncts; stool softeners/laxatives for severe chronic constipation; antidiarrheals only for chronic loose stool, not first-line.
• Hygiene: sitz baths (15-minute intervals, warm water, no salts/emollients) relax the pelvic floor and reduce prolapse/edema.
• Topical therapies: no quality evidence supports OTC creams/wipes/suppositories, but low side-effect profile makes continuing patient-perceived benefit reasonable; anesthetics (lidocaine) and steroids (hydrocortisone) common ingredients — steroid use >7 days risks anoderm thinning, daily topical use beyond 7 days risks dermatitis.
• Oral therapies: NSAIDs for discomfort/inflammation; phlebotonics (plant-derived flavonoid/ synthetic oral agents, US off-label/not FDA-approved but used in Europe/Asia) show modest meta-analytic benefit for pruritus/bleeding, including postoperatively (hemorrhoids are also listed among the anorectal-disorder causes of anal pruritus generally — see Pruritus Ani).

Office-based procedures (internal hemorrhoids, grade I–III / some III)

• Rubber band ligation (RBL) — band placed above the dentate line on redundant mucosa; tissue necroses over 5–7 days. Mainstay since the early 1960s; McGown suction ligator variant avoids needing an assistant grasper. More than one column may be banded per visit but at a cost of higher pain/urinary retention rates. Bleeding risk peaks post-procedure day 5–7 (tissue necrosis/band fall-off); anticoagulation is conventionally held except 80 mg aspirin, though a retrospective case-control study found no significant bleeding-risk difference for clopidogrel (3.75% vs. 2.78%, p=0.74). Rare but potentially fatal risk: pelvic sepsis (fever, urinary retention, swelling, pain — requires rapid recognition).
• Energy ablation — infrared photocoagulation (IPC; grade I–II, heat via tungsten-halogen lamp, 0.5–2 sec pulses, 2.5–3 mm depth) and bipolar diathermy (grade I–III, 20 W pulsed electrocautery, 2.2 mm depth); overly distal application risks pain/ulceration/fissure. RCT data show similar outcomes between the two; a crossover study found less analgesic use/bleeding with IPC vs. RBL in the first 24h, though RBL complication rates were typical for the technique.
• Sclerotherapy — oldest technique (first described 1869); 1–1.5 mL sclerosant (hypertonic saline or 5% phenol in oil) injected submucosally via 21-gauge needle at the hemorrhoid base; causes fibrosis/fixation. Safe on anticoagulation (unlike RBL). Comparable outcomes to RBL across multiple small trials with differing individual results — surgeon discretion.
• Thrombosed hemorrhoid excision — office excision of a thrombosed external hemorrhoid is time- critical: spontaneous improvement typically begins within 72 hours, so excision beyond that window mainly prolongs pain rather than helping. Topical nifedipine (reduces sphincter spasm) is an option for patients outside the excision window. Excision (elliptical incision, local anesthesia, dissection of the clot/hemorrhoid tissue) outperforms simple incision/clot evacuation for recurrence and pain.

Operative management (5–10% of hemorrhoid patients; best for grade III–IV, large external

component, incarcerated/strangulated/gangrenous disease)

• Excisional hemorrhoidectomy remains the gold standard — excellent results, minimal recurrence, few complications.
• Closed (Ferguson) technique — most common technique in the US; elliptical excision, pedicle suture-ligated, wound closed primarily with running absorbable suture.
• Open (Milligan-Morgan) technique — common in the UK; same excision/ligation, wounds left open to heal by secondary intent. A meta-analysis of 11 RCTs found closed technique associated with less postop pain, faster wound healing, and less postop bleeding than open — though several individual RCTs found little difference.
• Energy devices (bipolar diathermy, ultrasonic shears) modify either technique: a Cochrane review found less early postop pain with bipolar energy (difference gone by day 14) and faster operative time; ultrasonic shears show similar results.
• Whitehead hemorrhoidectomy — circumferential excision of internal hemorrhoidal tissue/ redundant anoderm just proximal to the dentate line; largely abandoned due to anal stenosis, mucosal ectropion ("Whitehead deformity"), and disturbed continence.
• Stapled hemorrhoidopexy — circular stapler creates a mucosa-to-mucosa anastomosis ~2 cm above the dentate line, excising redundant submucosa, relocating anal cushions cephalad, and interrupting feeding arteries. Does not address external hemorrhoids. Compared to excisional hemorrhoidectomy: less early pain/faster recovery in early cohort studies, but a 777-patient RCT and a 12-trial/1097-patient Cochrane review both found higher recurrence with hemorrhoidopexy (32% vs. 14% at 24 months in one RCT) and higher need for a further operative procedure, while excisional surgery patients were more likely to be fully asymptomatic postop — a real efficacy trade-off, not a wash. Unique, serious complication profile: rectovaginal fistula (see Rectovaginal Fistula, ASCRS Ch15, for that page's fuller iatrogenic-RVF content), staple-line bleeding, stricture; a 784-article/14,232-patient systematic review found a median 16.1% complication rate with 5 documented mortalities, and 40 published cases (2000–2009) of rectal perforation after stapled hemorrhoidopexy, most requiring laparotomy/diversion, 4 deaths — reflects the importance of training/technique, not a reason to avoid the technique outright.
• Doppler-guided hemorrhoidectomy (HAL/THD) — Doppler-probe anoscope identifies and suture-ligates each of the 4–6 feeding hemorrhoidal arteries (mucopexy often added for prolapse). Less tissue excision, less pain. A 28-study/2904-patient systematic review found a pooled recurrence rate of 17.5% (highest for grade IV), 5% bleeding rate, 6% reintervention rate. RCT vs. RBL for grade II–III found similar recurrence/QoL/continence but more early pain and higher cost with HAL. Meta-analyses show higher recurrence with HAL than stapled hemorrhoidopexy (OR 0.55 favoring hemorrhoidopexy) and recurrence highest in grade IV disease regardless of technique; HAL vs. excisional hemorrhoidectomy shows no significant recurrence difference in one meta-analysis, though long-term comparative data are described as "somewhat lacking."

Pain management and postoperative care

Multimodal, narcotic-sparing pain control is emphasized given known narcotic-related risks (constipation, addiction potential). A pudendal nerve block (1:1 lidocaine:bupivacaine mix, 40–60 mL, +/- 1:200,000 epinephrine) is standard for conscious sedation; liposomal bupivacaine (volume-expanded, injected as the block) extends analgesia to 72h and reduces time-to-first-opioid (19h vs. 8h in one RCT) at higher cost. Oral non-narcotic mainstays: scheduled NSAIDs (e.g. Motrin 600 mg TID) and acetaminophen (≤4 g/day); diazepam as an (unstudied but commonly used) adjunct for sphincter spasm. No formal guideline exists for postop narcotic prescribing; claims-database and single-institution data suggest 5–10 days / ~27 5-mg oxycodone-equivalent pills meets most patients' needs — preferentially prescribed without acetaminophen to avoid combination toxicity. Topical baclofen and glyceryl trinitrate (GTN) each show modest RCT benefit for pain, with GTN also significantly improving wound healing at 3 weeks (at the cost of more headache). Postop metronidazole data on pain reduction are mixed and not robust to sensitivity analysis. Routine care: aggressive constipation avoidance (fiber, water, stool softeners — fecal impaction postop can be devastating), sitz baths, and warm/cool packs.

Complications of hemorrhoidectomy

• Urinary retention — most common complication (1–15%), most common cause of ambulatory discharge failure; higher after spinal anesthesia and after HAL; risk mitigated by limiting IV fluids (<500 cc) and judicious local anesthetic use.
• Postoperative hemorrhage — delayed bleeding (0.9–10% incidence) is rare but serious; passage of a full bowel movement of clots warrants exam under anesthesia. No significant difference in bleeding between open vs. closed technique, or standard vs. bipolar-energy technique. Risk factors: excessive straining, infection, higher number of piles excised, male sex.
• Fecal incontinence — rare, multifactorial (anal sphincter overstretch, direct injury, loss of hemorrhoid-cushion bulk) — the postoperative/iatrogenic mechanism already named in Fecal Incontinence's sphincter-defect etiology section, now given its procedural detail here.
• Anal stenosis — most common after emergency hemorrhoidectomy, from inadequate skin bridges/ excessive anoderm removal; treated with bulk laxatives, dilation, anoplasty. Hemorrhoidectomy accounts for ~90% of all anal stenosis cases — see Anal Stenosis for the full classification, prevention detail (preserving mucocutaneous bridges, avoiding anterior/posterior midline resection), and reconstructive flap treatment ladder.

Special patient populations

• Strangulated hemorrhoids — incarcerated, irreducible, ± necrosis/ulceration. Absent prohibitive operative risk, expeditious excisional hemorrhoidectomy is preferred over reduction- then-banding (which had a 13.5% subsequent-hemorrhoidectomy rate in one small trial); necrosis makes excision mandatory.
• Pregnancy — hemorrhoidal engorgement/prolapse common (14.4% prevalence of prolapse in third trimester, 14.6% postpartum thrombosis in one Dutch cohort); symptoms almost always resolve after delivery. Surgery reserved for strangulation or severe symptomatic external thrombosis; use local anesthesia with left lateral decubitus positioning to avoid IVC compression.
• Portal hypertension / rectal varices — a distinct entity from hemorrhoids, not to be conflated: rectal varices provide portosystemic collateral circulation and, while common in portal hypertension, bleed much less often than esophageal varices. Hemorrhoid symptom incidence in portal hypertension patients matches the general population. Varix bleeding is addressed via medical/interventional portal decompression (TIPS, portosystemic shunt, liver transplant) first; direct control (sclerotherapy, suture ligation) has higher success once the portal system is decompressed.
• Crohn's disease — hemorrhoidectomy carries an older reputation for poor wound healing in Crohn's patients, and some case series describe hemorrhoidectomy with poor outcome preceding an IBD diagnosis — a cautionary note relevant to Crohn Disease's perianal disease content, though not yet cross-linked there in detail (see Open items below). In appropriately selected, medically well-controlled patients without rectal inflammation, good outcomes are achievable (90% healing in one series of well-controlled ileocolonic Crohn's; good THD outcomes in a small series without rectal involvement).
• Immunocompromise (transplant/steroid/chemotherapy-induced, or HIV) — for reversible immunocompromise, conservative management until near-normal immunity; for ongoing immunocompromise, medical management is primary, direct intervention reserved for medical failure. RBL and excisional hemorrhoidectomy have been shown safe in HIV-positive patients on HAART with acceptable CD4 counts (see Anorectal Sexually Transmitted Infections for the fuller HIV-anorectal-disease framework — T4-cell count has shown no predictive value for wound healing, and HAART-era outcomes data supersedes older pre-HAART concerns about delayed healing in AIDS patients).

Treatment algorithm (per chapter's summary figure)

History/exam plus malignancy exclusion (colonic/rectal imaging as indicated) drive grade-based management: Grade I — dietary manipulation, office ablation (bipolar/IPC), or sclerotherapy (ALTA); Grade II — RBL, bipolar/IPC, or THD; Grade III — hemorrhoidectomy, or selectively stapled hemorrhoidopexy/THD; Grade IV or mixed hemorrhoid — hemorrhoidectomy.

Related pages

• Colorectal Anatomy & Embryology — normal hemorrhoid anatomy/embryology this page's pathogenesis and treatment content builds on; closes that page's previously-flagged Ch11 gap.
• Anorectal Physiology — hemorrhoid-cushion contribution to resting continence.
• Rectal Prolapse (Procidentia) — the concentric-vs-radial-fold exam distinction from true rectal prolapse.
• Fecal Incontinence — hemorrhoidectomy as a named iatrogenic cause of sphincter-defect incontinence; thrombosed hemorrhoid in the anorectal pain differential.
• Crohn Disease — special-population surgical caution.
• Anorectal Sexually Transmitted Infections — fuller HIV-anorectal-disease framework backing this page's HIV/immunocompromise special-population content.

Open items / gaps

• ~~Crohn's-specific hemorrhoidectomy caution is not yet reciprocally cross-linked into Crohn Disease's perianal disease section — worth doing when that chapter's dedicated content (ASCRS Ch47, "Anorectal Crohn's Disease") is ingested, rather than a premature partial edit now.~~ Resolved (2026-08-25) — Crohn Disease's new "Perianal (anorectal) Crohn's disease" section now covers hemorrhoids in CD, sourced from ASCRS Ch47 - Anorectal Crohn's Disease.
• No dedicated wiki page yet for portosystemic rectal varices as their own entity — currently only covered as a differential note within this page.