Physical Address
304 North Cardinal St.
Dorchester Center, MA 02124
Anatomy
The anal canal is about 4 cm long in adults, and is the terminal and most inferior part of the large intestine. It begins where the rectal ampulla narrows abruptly below the level of the U-shaped sling formed by the puborectalis muscle and ends at the anal verge, which is the external outlet of the GI tract. The anus is normally contracted, forming an anteroposterior slit, except during defecation. The anal canal, surrounded by the internal and external anal sphincters, descends posteroinferiorly between the anococcygeal ligament and the perineal body. It is also surrounded by the levator ani muscles, which form the main part of the pelvic diaphragm. Because the anal canal slopes posteroinferiorly, the examining finger or instrument should be directed toward the umbilicus when introduced into the anal canal.
The lining of the anal canal consists of an upper mucosal (endoderm) segment and lower cutaneous (ectoderm) segment. The dentate (pectinate) line is the “saw-toothed” junction between these 2 segments, each of which differs in venous and lymphatic drainage, nerve supply, and epithelial lining ( Fig. 129.1 ). Above this level, innervation is via the sympathetic and parasympathetic systems. The arterial supply and venous drainage are related to the internal iliac vessels, as well as the superior hemorrhoidal artery and vein. The lymphatics accompany these vessels and drain into the internal iliac nodes. Distal to the dentate line, the anal canal is innervated by the somatic nervous system, with blood supply and drainage from the inferior hemorrhoidal system. Lymphatic drainage below the dentate line is into the inguinal lymph nodes (see later in this section). These differences are important for the classification and treatment of hemorrhoids.
Embryologically, the dentate line represents the junction between endoderm and ectoderm. Proximal to this line pain sensation is negligible, and biopsy can be done with no or little anesthesia. Below the dentate line, however, the anoderm is highly sensitive, an important point to note when examining the anal canal, or applying hemorrhoid bands.
Above the dentate line are 6 to 14 pleats of tissue called the Columns of Morgagni. These are a consequence of funneling of the rectum as it narrows into the anal canal. Located between the bases of the columns of Morgagni are anal crypts that lead to small, rudimentary anal glands. When compressed by the passage of stool, the anal glands exude mucus, which aids in evacuation of stool through the anal canal. These glands extend into the internal anal sphincter. If they become blocked, an anal abscess or fistula can develop.
The cutaneous part of the anal canal consists of modified squamous epithelium that is thin, smooth, delicate, and devoid of hair follicles or glands; this is the anoderm. At the level of the anal verge the epithelium becomes thicker, and skin appendages begin to be seen.
The arterial blood supply of the anus and rectum is from the superior, middle, and inferior hemorrhoidal arteries, which are continuations of the inferior mesenteric, hypogastric, and internal pudendal arteries, respectively. Klosterhalfen and coworkers performed postmortem angiographic, manual, and histologic evaluations to show that in 85% of people, the posterior anal canal is less well perfused than other areas of the anus. In a pathogenetic model of primary anal fissure, this diminished blood supply could result in relative ischemia at the posterior commissure, which explains not only why anal fissures at this location may become chronic, but also why they can be healed by smooth muscle relaxants that act as vasodilators (e.g., nitroglycerin, diltiazem) with resulting increased blood supply. The venous drainage from the anal canal is by both the systemic and portal systems. The internal hemorrhoidal plexus drains into the superior rectal veins, which drain into the inferior mesenteric and then into the portal vein. The distal anal canal drains via the external hemorrhoidal plexus through the middle rectal and pudendal veins into the internal iliac vein (i.e., the systemic circulation).
Lymph from the upper two thirds of the rectum drains exclusively upward to the inferior mesenteric nodes and then to the para-aortic nodes. Lymphatic drainage from the lower third of the rectum occurs not only cephalad, along the superior hemorrhoidal and inferior mesenteric arteries, but also laterally, along the middle hemorrhoidal vessels to the internal iliac nodes. In the anal canal, the dentate line is the watershed for lymphatic drainage: above, to the systemic drainage system, and below, to the inguinal drainage basin. Therefore, inguinal adenopathy can be seen with malignant disease below the dentate line, whereas with more proximal lesions, the nodal drainage is into the pelvis.
The internal anal sphincter is an involuntary sphincter surrounding the superior two thirds of the anal canal. It is formed by a thickening of the circular smooth muscle layer of the intestine, and innervated by the pelvic splanchnic nerves (parasympathetic). This sphincter reacts (relaxes) to the pressure of feces in the rectal ampulla and is the major determinant of anal canal resting tone and passive continence.
The external anal sphincter is a relatively large voluntary muscle that surrounds the inferior two thirds of the anal canal. It forms a broad band on each side of the anal canal and consists of subcutaneous, superficial, and deep elements. The external anal sphincter partly overlaps the inferior part of the internal anal sphincter. It is composed of skeletal muscle and contributes to our conscious control of defecation. The external anal sphincter assists in voluntarily closing the anus. The puborectalis muscle is the deepest component of the external anal sphincter, and its contraction draws the upper anal canal anteriorly, creating an angle between the axis of the anus and that of the rectum. Relaxation of the puborectalis straightens that angle, facilitating evacuation. The innervation of the external anal sphincter is the inferior rectal nerve, and the perineal branch of S4.
Examination of the Anus and Rectum
All routine adult physical examinations should include a digital examination of the anorectum. When patients present with problems related to the anorectal region or colon, a more comprehensive examination is indicated. Examination begins with a thorough history. Active listening allows the patient to explain his or her symptoms, the physician to develop rapport with the patient, and for the patient’s anxiety to abate. Specific questions about duration of symptoms, exacerbating or alleviating factors, and medical or surgical treatments already used must be asked. The patient also should be asked about his or her normal bowel regimen, any recent changes in bowel habit, sexual history (e.g., anal intercourse), and family history with regard to colorectal cancer, polyps, and IBD. The patient’s history will usually permit the physician either to identify the likely diagnosis or narrow the number of possibilities considerably.
Very often, patients with anorectal problems delay seeking medical care out of fear and embarrassment. It is important to explain each step of the anorectal examination before it is done. Let patients feel you touch them before you approach a sensitive area, and remember that any surprising contact will increase the anxiety you are trying to minimize. It is important to avoid causing pain during the examination. A calm voice and gentle touch are essential. Even so, there are times when the patient is so tender that digital exam cannot be performed, and examination under anesthesia must be done.
Patients can be examined in the office in any one of several positions, including left lateral, knee-chest, or prone jackknife. In the prone jackknife position, the patient is face-down, on his or her knees, with the arms folded and the shoulders and head on the examining table. A special hydraulic table is usually used, allowing the bed to be elevated and tilted head-down. The knee-chest position is assumed on a flat examining table, with the patient kneeling, then leaning forward to expose the anal area. This position is least commonly used. The lateral position allows examination with the least patient contortion, though exposure of the anus may require an assistant. There is no clear best position, but appropriate illumination is critical.
Inspection
The examination begins with inspection of the skin. In some cases, looking at the patient’s underwear will give a clue to the presence and character of anal drainage, or whether there is evidence of incontinence. As the buttocks are gently retracted, scars, skin abnormalities, stool, discharge of blood or pus, anal tags, warts, hemorrhoids, external openings suggesting fistulae and lesions adjacent to or prolapsing from the anal canal are noted. The anus is inspected for asymmetry, gaping, or scars. If incontinence is a part of the symptom complex, stroke the perianal skin gently to assess the presence or absence of anal wink reflex. An intact anal wink indicates sphincter innervation, whereas an absent wink can be caused by either sensory or motor deficit.
The patient is then asked to squeeze the anus to evaluate movement of the anal sphincter, and assess for recruitment of gluteal muscles. There should be concentric movement of the anus and perianal skin. Next, the patient should be asked to strain so that perineal descent can be assessed; there should be <4 cm of descent below the resting level. Prolapse of the vagina or rectum, bulging hemorrhoids, or leakage of urine or stool should be noted during straining. If prolapse is reported by the patient, but not seen during the exam, the patient can be asked to strain while sitting on the toilet.
Traction applied laterally to each side of the anal orifice with a gauze pad allows eversion of the distal anus for further inspection. This is particularly useful in demonstrating anal fissure without causing undue pain ( Fig. 129.2 A and B ). The nearby skin of the buttocks, paravaginal region, base of the scrotum, and the gluteal cleft should also be examined. Inguinal lymph nodes should be assessed if infection or neoplasia is suspected.
Palpation
Using a gloved and lubricated index finger, the examiner palpates the anal canal and perianal skin. Slow insertion and gentle pressure are appropriate. Assessment of resting anal pressure and anal canal length are noted at this time. As the patient is asked to squeeze his or her anus, the anal sphincter is assessed for strength and for areas of deficiency. The index finger is then swept circumferentially around the anal canal, noting scars, masses, or tenderness. Internal hemorrhoids are not usually palpable unless they are thrombosed. Lastly, the finger is advanced into the rectum to assess the prostate gland and the rectovaginal septum, and to check for mass lesions. In the presence of anal pain, the examining finger should be pressed away from the area of tenderness upon insertion. If the examination cannot be done, use of sedation or anesthesia may be warranted. Approximately 80% of the resting anal canal pressure is contributed by the internal anal sphincter. The external sphincter is evaluated by having the patient voluntarily squeeze the anus around the examining finger; the external sphincter contributes about 20% of resting anal canal pressure.
Abnormalities often appreciated in the anal canal include fistula tracts, which feel like a cord, or linear induration; the internal opening of a fistula, which feels like a small area of induration; cancers, which may be firm and hard; and ulcers, which can feel uneven and craterous. Palpation anteriorly in a woman may reveal a rectocele or anterior defect in the sphincter complex.
Palpation of the distal rectum allows the detection of mass lesions, including polyps and cancers. Attention should be directed to the exact location of the lesion (anterior, posterior, right, left, and distance from anal verge) and its size, mobility, and character (soft, ulcerated, hard, or pedunculated). Lesions outside the rectal wall also may be appreciated. The cervix and prostate can be felt through the anterior rectal wall in women and men, respectively. The character of the prostate should be noted, along with any hard nodularity that could represent cancer. The full extent of the prostate may not be palpable. The rectal mucosa should be assessed for its texture; in patients with proctitis, for example, the mucosa can feel rough and gritty; in patients with hypoalbuminemia it can feel wet and slippery.
The levator muscles should then be palpated. Patients with functional anal pain may exhibit levator tenderness on examination. Similarly, the coccyx should be palpated between the examining index finger internally and the index finger of the opposite hand pressed over the coccyx externally. This maneuver is done to look for pain with motion (coccydynia), as might be present with a coccygeal fracture.
Finally, the contents of the rectum should be assessed regarding the character and amount of stool. When the index finger is removed, any stool, blood, pus, or mucus on the glove should be noted.
Endoscopy
The decision to perform an endoscopic examination depends on the findings on history and physical examination and usually is necessary for the evaluation and exclusion of organic disease in patients with fecal incontinence, constipation, unexplained anal pain, anemia, diarrhea, and rectal bleeding. Colonoscopy is discussed at length elsewhere, and is not repeated in this chapter.
Anoscopy
Anoscopy allows inspection of the anal canal, dentate line, internal hemorrhoids, and distal rectum; this is the best method of viewing the anal canal. The anoscope is a short metal or plastic tubular device, usually with a beveled end; most are <2 cm in diameter and have internal illumination or are used with external lighting sources.
Digital rectal exam always precedes anoscopy. Afterwards, the lubricated anoscope is inserted slowly as the examiner applies gentle pressure on the obturator until the instrument has been fully advanced. An anoscope should never be inserted without the obturator in place. The obturator is then removed, and the entire anal canal is examined. This includes inspection of the distal rectal mucosa, the anal transition zone, and the anal canal to the anal verge. Some scope models have a bevel, or slot, to better see the anal tissue and these may require several re-insertions to view the entire anal canal. Internal hemorrhoids can be seen bulging above the dentate line or prolapsing distally. Internal fistula openings, when seen, will usually be at the dentate line and pressure at the external opening may allow pus to be seen at the internal opening.
A variant of anoscopy called high-resolution anoscopy (HRA) is used to detect anal intraepithelial neoplasia (AIN) and is performed on individuals who are at high risk for anal human papillomavirus (HPV) infection and those with an abnormal anal Pap test. HRA allows the anal mucosa to be seen greatly magnified, with augmented visualization of abnormal areas by staining with acetic acid and Lugol solution.
Rigid Proctoscopy
Rigid proctosigmoidoscopy uses a rigid scope that is 25 cm long and 11 mm in diameter. It requires a light source for visualization. In spite of the wide application of flexible endoscopes, there remain instances when a rigid scope is advantageous. Rigid proctosigmoidoscopy can more precisely measure the distance of rectal lesions from the anal verge than can flexible endoscopy. The rigid instrument also can allow the precise location of a lesion on the wall of the rectum, whereas flexible scopes cannot easily determine anatomic left versus right and anterior versus posterior positions, which may be essential in planning surgery. A rigid proctoscope is sometimes quicker and easier to use than a flexible instrument when evaluating the rectum, performing a biopsy, or aspirating fecal contents. The biopsy forceps used with flexible endoscopes can also be used through the rigid scope, although rigid alligator-toothed forceps are preferred. The exam is initiated exactly as is anoscopy. Once the scope has been advanced into the rectum (approximately 4 to 5 cm), the obturator is removed and the scope window closed. Further advancement of the scope is performed under direct vision, insufflating air as needed to distend the lumen of the rectum.
Flexible Sigmoidoscopy
The flexible sigmoidoscope is simply a shorter version of a colonoscope, measuring 60 cm in length, although today, a gastroscope is more commonly used for flexible sigmoidoscopy (FS) when a full evaluation of the colon is not required. One or 2 enemas are given before the examination, and sedation typically is not used, which is the reason patients who have undergone both colonoscopy and FS generally find the former less unpleasant. The goal of FS is to inspect up to the left colon, which should be reachable at least 80% of the time. Lesions can be biopsied and polyps removed, although the presence of polyps usually mandates full colonoscopy. Use of electrocautery and argon plasma coagulation should be avoided unless full bowel preparation has been done, as intracolonic explosions have occurred from ignition of bowel gas.
FS can be used to enhance the diagnostic capability of barium enema, which at times fails to show the distal rectum optimally because of the obscuring effect of the balloon needed to distend the colon. Lesions of the rectum and sigmoid seen on radiologic studies also can be evaluated by FS. FS permits serial examinations and treatment of diseases located in the rectosigmoid and left colon, such as proctosigmoiditis and radiation proctitis. FS is also useful for following cancers, allowing the rectosigmoid anastomosis to be seen in between colonoscopic examinations.
Hemorrhoids
Physicians face several unique problems when evaluating a patient complaining of hemorrhoids. First, patients often attribute any anal symptoms to hemorrhoids. In our practice, the majority of patients whose chief complaint is “hemorrhoids” have some other explanation for their symptoms (e.g., fissure, pruritus ani, warts). Second, hemorrhoids are a normal part of our anatomy , and their presence does not necessarily imply a disease state; a corollary to this is that hemorrhoids can be expected to coexist with other anal pathology. Third, the multitude of therapeutic options available for treating hemorrhoids ensures there is no one treatment that is appropriate for all patients. Lastly, patients are often fearful of hemorrhoid surgery, a fear that may lead to delay in seeking treatment.
Hemorrhoids are dilated vascular channels between the anal mucosa and underlying internal anal sphincter. They typically occur in the left lateral, right posterior, and right anterior positions. “Hemorrhoids” located elsewhere should raise concern for other diseases (e.g., carcinoma, lymphoma, condyloma). Internal hemorrhoids originate above the dentate line and are covered by columnar or transitional mucosa. External hemorrhoids are distal to the dentate line and are covered by squamous epithelium. Hemorrhoid complaints are common, accounting for 1.9 to 3.5 million visits to physicians annually in the USA. Common symptoms attributable to hemorrhoids include bleeding, prolapse, and swelling. Pain usually occurs only with thrombosis.
Hemorrhoid treatments have been recorded throughout human history. It is sobering to realize how closely today’s treatments resemble those used for millennia: The Edwin Smith Papyrus (1700 BCE) describes treatment with an infusion of acacia leaves, which is remarkably similar to the witch hazel that is used today. Cautery was applied by Hippocrates (400 BCE); refined method of cautery with laser-emitting fiber was described in 2017. Ligation of hemorrhoids was described by Celsus (25 BCE to 14 AD), and compares favorably to Doppler guided therapy in 2012.
Internal Hemorrhoids
Internal hemorrhoid symptoms occur because of loss of connective tissue support and resulting protrusion, or prolapse of the vascular tissue, rendering it more susceptible to trauma from straining or the passage of hard stools ; Symptoms of internal hemorrhoids are associated with increased levels of circulating matrix metalloproteinases, , and are more likely in patients with constipation, loose stools, or in those who sit on the toilet for prolonged periods of time. Bleeding is painless and may be on the tissue or in the toilet. Bleeding also may be described as dripping, and bright red. Less commonly it can accumulate in the rectum and be passed as dark blood, or clots. Internal hemorrhoids also may prolapse, and are graded as follows: grade I hemorrhoids bleed, and may be enlarged, but do not prolapse; grade II hemorrhoids protrude with defecation and reduce spontaneously; grade III hemorrhoids prolapse and require manual reduction; grade IV hemorrhoids remain prolapsed. Prolapsed hemorrhoids may cause blood or mucus on the patient’s underwear. Perianal moisture resulting from prolapse can cause itching. Although the exact incidence of hemorrhoidal disease is unknown, it is thought to present in 10% to 25% of the adult population.
Evaluation
The diagnosis of internal hemorrhoids is made by history and physical examination, augmented by anoscopy using a beveled or slotted anoscope. Gentle eversion of the anal margin may reveal prolapsing hemorrhoid tissue. Internal hemorrhoids also may be seen with FS on retrograde view. Anoscopy allows visualization of the degree of protrusion. The exam may be entirely normal in between periods of symptoms.
Treatment
Initial treatment of symptomatic internal hemorrhoids is medical and consists of adequate fluid intake (6 to 8 glasses of nonalcoholic, noncaffeinated beverage daily), adequate dietary fiber (20 to 30 g daily), and avoidance of straining and prolonged time on the toilet. , Patients may keep a diet diary to assess their fiber intake and then either alter their diet or add supplemental fiber, if necessary. If stools remain hard, stool softeners such as docusate sodium can be added. Laxative and enemas are rarely needed ; these measures are also useful in preventing hemorrhoidal recurrence. Hard stools or constipation symptoms may be treated with polyethylene glycol 3350 or docusate when fiber therapy alone is insufficient. Topical creams such as phenylephrine/mineral oil/petrolatum or glucocorticoid-based creams may temporarily improve pain or itching. A caution in the use of glucocorticoid-based topical agents is predisposition to infection, e.g., candidiasis. Glycerin suppositories have little, if any, role in treating hemorrhoids.
Phlebotonics are a heterogenous group of compounds including plant extracts or flavonoids, and are superior to placebo in treating acute hemorrhoid symptoms. They improve venous tone, stabilize capillary permeability, and are useful in alleviating bleeding from hemorrhoids; they have an excellent safety profile. Diosmiplex (Vasculera, Ferndale Laboratories), is one such product we sometimes add in the treatment of grade II and III hemorrhoids that have failed to resolve with fiber therapy and counseling.
Persistent bleeding or hemorrhoid prolapse unresponsive to medical therapy or grade IV prolapse are indications for procedural therapy. Treatment can be either excisional or non-excisional. Non-excisional treatments are designed to affix the vascular cushion to the underlying internal sphincter. Options to achieve such fixation include rubber band ligation (RBL), sclerotherapy, cryotherapy, infrared photocoagulation, suture ligation, and many others.
Rubber Band Ligation
RBL is the most common office procedure for the treatment of hemorrhoids. It is usually applied to grade II and III hemorrhoids that are unresponsive to medical management. In addition to creating a scar and fixing the mucosa to the underlying tissue, a small amount of hemorrhoidal tissue is actually removed when the RBL-entrapped tissue becomes necrotic and sloughs. Grade I hemorrhoids may be too small to allow the band to be directly applied, although a band placed proximal but close to the hemorrhoidal tissue may accomplish the same fibrotic effect. Grade IV hemorrhoids more often require surgical excision.
Rubber bands are usually applied by the surgeon via a slotted anoscope and by the gastroenterologist using a gastroscope in the retroflexed position or one of the newer techniques involving a small plastic suction device (CRH-O’Regan banding system or the ConMed SpaceBander) preloaded with a single band. There is debate whether bowel preparation is required, but it is recommended in patients who are diabetic or immunocompromised and, therefore, more predisposed to infection. If view of the hemorrhoid is obscured because of retained stool, a single sodium biphosphate and sodium phosphate enema may be used. Antibiotics are not routinely used. Bands are placed just proximal to the internal anal hemorrhoid, above the dentate line. Distal placement that entraps squamous mucosa results in pain, and the band must be removed immediately; bands should not be placed distal to the dentate line, and are not used for external hemorrhoids. The number of bands placed per treatment session is controversial. Although studies have shown that multiple bands can be placed safely during a single procedure, , often one site is banded per office visit in order to minimize pain and reduce complications. If multiple sites are banded at one sitting, adding local anesthesia is helpful. The patient is reassessed in 4 to 6 weeks, and repeat banding performed, if needed. Most patients can be managed with 3 or fewer procedures. Often the offending column is easily seen and resolved with application of a single band.
Patients sometimes experience pain after RBL. They are advised to soak in a warm tub and use acetaminophen. Narcotics are sometimes required. Immediate, severe pain signals too distal band placement, and the band should be removed or repositioned. Symptoms vary from patient to patient. Most patients experience a feeling of rectal fullness or urge to defecate, which can last a day or 2; some experience no symptoms at all. Fiber and water should be continued as described earlier. RBL is successful in 75% of patients with grade I and II hemorrhoids and in 65% of those with grade III hemorrhoids. Recurrence occurs in about 20% of hemorrhoids so treated.
Major complications from RBL include bleeding, sepsis, cellulitis, and death. Some bleeding is common 4 to 7 days after the procedure, when the band usually sloughs. About 1% of patients develop severe bleeding requiring treatment, although bleeding sometimes ceases without intervention. Bleeding may be controlled with injection of epinephrine, suture ligation, or tamponade with a large-caliber Foley catheter balloon placed in the rectum. Severe bleeding mandates observation, as quantification of rectal blood loss is difficult. Patients may become hypotensive, and rebleeding may occur. Ideally anticoagulants should be stopped prior to RBL, and not resumed for 7 to 10 days, though adherence to this recommendation must take into account the medical indication for anticoagulation. RBL should not be electively performed in patients who are taking anticoagulants, and if anticoagulation cannot be stopped, suture ligation should be used in lieu of RBL.
A serious complication of RBL is sepsis, which can be life threatening. Sepsis usually occurs 2 to 8 days after banding and should be considered in patients with worsening pain, difficulty urinating, and fever; these symptoms should be asked about when patients call with concerns after RBL. Patients at greatest risk for sepsis are those who are immunocompromised or have hematologic malignancies. Because of the increased risk of sepsis in immunocompromised patients, suture ligation rather than RBL is preferred. There is no demonstrated efficacy for prophylactic antibiotic use for this procedure. Treatment is surgical debridement and IV antibiotics.
Sclerosing Agents
Injection therapy for hemorrhoids has been practiced for more than 100 years. The goal is to inject a sclerosant into the submucosa above the internal hemorrhoid at the anorectal ring (this area does not have somatic innervation). The fibrosis created results in shrinking of the hemorrhoid and fixation of the hemorrhoid to the underlying internal sphincter muscle, thereby preventing prolapse. Usually 3 to 5 mL of sclerosant is injected at the apex of the hemorrhoid column. The most common sclerosant is 5% phenol in an oil base. This treatment is most successful in patients with grade I and II hemorrhoids.
Sclerotherapy can produce a dull pain for up to 2 days after injection. Sepsis rarely can occur and typically presents 3 to 5 days after treatment. Symptoms include perianal pain or swelling, watery anal discharge, and fever. Leukocytosis usually is present. Prompt surgical intervention and IV antibiotics are mandatory. , Sclerotherapy is often offered to AIDS patients because of their increased risk of complications with RBL.
Cryotherapy
Cryotherapy uses liquid nitrogen to freeze tissue, thereby destroying the hemorrhoid complex. It has fallen out of favor because of difficulty controlling the amount of tissue destroyed, the time it takes to perform the procedure, and the foul-smelling discharge resulting from tissue necrosis.
Infrared Photocoagulation
Infrared photocoagulation uses infrared radiation to coagulate tissue, leading to fibrosis. It is applied for 1.5 seconds to 2 or 3 sites proximal to the hemorrhoidal plexus. Multiple sites can be treated at the same visit. It is most useful for grade I and II hemorrhoids, with reported results as good as those obtained with RBL or sclerotherapy. In our experience, it is most suited for grade I hemorrhoids, especially in patients who have experienced pain with RBL. Larger hemorrhoids do less well with this treatment. Pain and other complications are rare with this procedure.
Surgical Therapy
Patients with hemorrhoids have increased anal canal pressure. Anal dilation and sphincterotomy to reduce pressure were performed in the past, but have no role in the treatment of hemorrhoids today. Sphincterotomy is sometimes performed at the time of hemorrhoidectomy in patients with concomitant anal fissure.
Hemorrhoidectomy is the procedure of choice for patients with grade III hemorrhoids that are unresponsive to other measures, for most patients with grade IV disease, and for those who have symptomatic external hemorrhoids unresponsive to conservative treatment. This can be performed under local, regional, or general anesthesia and is usually done as a day-surgery procedure. The wounds may be left open or closed, and the excision performed with scalpel, cautery, or other energy device. , , Long-term follow-up reveals a 26% recurrence rate at a median of 17 years, with 11% requiring an additional procedure of some sort.
The most significant drawback to surgery for hemorrhoids is post-operative pain. Essentially every alternative to surgery mentioned, as well as every technical variation discussed, represents an attempt to minimize pain while alleviating the symptoms troubling the patient. Many adjuncts have been shown to decrease pain after hemorrhoidectomy, including topical agents such as glyceryl trinitrate, , anesthetic cream, sucralfate, topical 2% atorvastatin, topical cholestyramine, and a long-acting local anesthetic of liposome bupivacaine.
Two other surgical procedures deserve mention because they are widely used and provide symptom relief similar to hemorrhoidectomy in selected patients, although with decreased pain. These are the procedure for prolapsing hemorrhoids (PPHs), also referred to as stapled hemorrhoidectomy or hemorrhoidopexy, and Doppler-guided hemorrhoid artery ligation. The PPH was introduced in 1998 by Longo and uses a circular stapling device which excises a circumferential ring of mucosa just above the anorectal ring, interrupting the vascular supply to the anal cushions and restoring them to their correct positions ( Fig. 129.3 ). It is used for grade II, III, and IV hemorrhoids, but with best results in grades II and III. Results of a randomized multicenter experience in the USA compared the PPH with excisional hemorrhoidectomy and showed that PPH-treated patients experienced significantly less pain. A similar trial in the United Kingdom showed improved outcomes, other than pain, with surgical hemorrhoidectomy. Another study comparing PPH with RBL found that more patients reported pain and an increased risk of postoperative bleeding with PPH; however, more patients in the RBL group required subsequent hemorrhoidectomy for persistent symptoms.
PPH can have significant postoperative complications, of which bleeding and urinary retention are most common. Severe, persistent postoperative pain occurs in one third of patients and may be related to placing the staple line too close to the dentate line. The frequency of this complication has diminished use of this technique; additionally, defecation urgency can be persistent in up to 28% of patients. Perhaps the most feared complication of PPH is pelvic sepsis leading to death. Long-term results from prospective randomized studies comparing hemorrhoidectomy and PPH suggest a higher rate of recurrent symptoms in the PPH group. ,
Doppler-guided hemorrhoidal artery ligation was described in 1995 and allows a Doppler probe to guide suture placement in the lower rectum to interrupt blood flow to the anal canal. It is reported to have a recurrence rate of 9.0% for prolapse, and 7.8% for bleeding at 1 year. A recent study showed similar results using ligation with and without Doppler guidance, suggesting the efficacy of the procedure is related to extensive ligation.
Both PPH and ligation will control symptoms related to internal hemorrhoids. Comparing the 2 suggests somewhat better symptom resolution with PPH, but at the cost of increased pain and bleeding. , Neither specifically addresses external hemorrhoids, which should be excised at the time of surgery if symptomatic. Table 129.1 summarizes the treatment options for internal hemorrhoids.
TABLE 129.1
Treatment Options for Internal Hemorrhoids
| Type of Treatment | Hemorrhoid Grades | Success Rate | Comments |
|---|---|---|---|
| General | |||
| Diet (increase in fiber and fluids) and bowel habit modification | 1-4 | Unknown | Patients with all grades of hemorrhoids should use these measures (see text) |
| Patients with high grades of hemorrhoids will need additional therapy | |||
| Endoscopic | |||
| Sclerosing agent | 1-4 | 75% | May be the favored treatment of patients with AIDS (successful results even with grade 3 and 4 hemorrhoids) |
| Life-threatening sepsis rarely complicates therapy | |||
| Rubber band ligation | 2 and 3 | 65%-75% | Grade 1 hemorrhoids are too small, and grade 4 hemorrhoids are usually too large for this procedure |
| The most commonly performed office procedure for hemorrhoids | |||
| Life-threatening sepsis rarely complicates therapy; 1% risk of severe hemorrhage when the band(s) sloughs | |||
| Infrared coagulation | 1 and 2 | Less than for rubber band ligation | Equipment for the procedure is expensive |
| Complication are rare | |||
| Surgical | |||
| Excisional hemorrhoidectomy | 3 and 4 | >85% on 10-year follow-up | External tags may be removed at the time of the surgical procedure |
| Postoperative pain is pronounced | |||
| Procedure for prolapsing hemorrhoids ∗ | 3 and 4 | >75%; several studies show higher long-term recurrence rates than with excisional hemorrhoidectomy | Newer procedure |
| Overall, significantly less postoperative pain than with excisional hemorrhoidectomy, but some patients experience severe, persistent postoperative pain or defecation urgency | |||
| Pelvic sepsis and death have been reported after this procedure | |||
No physician performs every described hemorrhoid procedure. Each physician treating hemorrhoids develops their own approach, balancing risks, pain, and efficacy. There are always patients for whom variation in one’s treatment routine is necessary. Our approach is to treat patients with grade I, II, and III hemorrhoids initially with fiber supplementation, water, and counselling. Persistent bleeding or prolapse in spite of medical treatment requires procedural intervention. RBL is our procedure of choice for most such patients. In patients with grade I hemorrhoids with persistent bleeding, infrared coagulation is used. For most patients with significant external hemorrhoids contributing to their symptoms, excisional hemorrhoidectomy is performed. For patients with grade II or III hemorrhoids and no significant external component, Doppler ligation or hemorrhoidectomy is usually performed, though PPH also may be used.
External Hemorrhoids and Anal Tags
You're Reading a Preview
Become a Clinical Tree membership for Full access and enjoy Unlimited articles
If you are a member. Log in here