These are one of the most common conditions, and over half of the population over 30 years old suffers from them. Many people tend to neglect the issue and only seek medical attention many years after the initial symptoms appear.
WHAT ARE HEMORRHOIDS?
In the past, they were incorrectly referred to as "varicose veins of the anus and rectum." Hemorrhoids can be considered as clusters of vascular tissue (arterial and venous) located beneath the mucosa in the last section of the rectum, which play a role in the continence mechanism. To simplify, let's imagine lining the inside of a funnel with red velvet; the funnel represents the rectum, and the red velvet represents its mucosa. Now, let's imagine looking at our funnel from the inside, from top to bottom: at the end of the funnel (the rectum), beneath the red velvet lining (rectal mucosa), just before the neck (anal canal), there are cushions (hemorrhoids) that, like a diaphragm in a camera, collapse to prevent gas from escaping. Therefore, the hemorrhoidal plexus is present in all individuals. Hemorrhoidal disease is diagnosed when, for the reasons we will discuss, they become symptomatic.
WHAT ARE THE CAUSES OF HEMORRHOIDS?
The causes of hemorrhoidal disease are multiple. Hereditary factors are often implicated, but their high prevalence suggests other factors, such as constipation or diarrhea, excessive straining during bowel movements, a sedentary lifestyle, a diet lacking in fiber, and smoking. Less frequently, hemorrhoids can be an expression of more complex liver conditions (e.g., cirrhosis). Predisposing factors can include advanced age and pregnancy.
I'VE HEARD OF GRADE IV HEMORRHOIDS: WHAT ARE THEY?
To simplify, hemorrhoids can be classified into I, II, III, and IV grades. Grade I hemorrhoids are internal, located at the end of the rectum, and may bleed during or after defecation. They usually do not cause pain. If the rectal mucosa prolapses, sliding down into the anal canal, it brings the hemorrhoids along with it, and these are considered Grade II. If the prolapse extends beyond the anal canal, the hemorrhoids move outside of the anus but spontaneously retract or can be manually pushed back after a bowel movement (Grade III). When the prolapse of the rectal mucosa is more severe, the hemorrhoids remain constantly outside of the anus, regardless of bowel movements; in this case, they are referred to as Grade IV hemorrhoids.
WHAT ARE THE SYMPTOMS?
The symptoms depend on the grade of the hemorrhoids, or more precisely, the extent of prolapse. The most common symptom is bright red bleeding (hemorrhoids contain both arterial and venous blood) during defecation. Bleeding may persist for a few minutes after defecation and can be accompanied by anal burning, less frequently significant pain. Outside of defecation, during the day, symptoms depend on the extent of mucosal-hemorrhoidal prolapse (i.e., the degree of their "descent" into the anal canal or outside of the anus). Common symptoms include itching and soiling (small mucous leakage from the anus with a feeling of anal wetness). Hemorrhoids can also manifest acutely with intense pain and the appearance of swelling that can affect the entire anus or a part of it. The patient may feel a very painful, dark-colored hard lump that can also grow to significant sizes. The blood clot that forms within this swelling gives it the characteristic dark color. This condition is referred to as acute hemorrhoidal thrombosis and always causes pain for the patient.
HOW ARE HEMORRHOIDS DIAGNOSED?
A medical history and an anoscopy are sufficient to make the diagnosis. However, since hemorrhoid symptoms are similar to those of more serious conditions, it's a good practice to undergo a traditional or virtual colonoscopy after the age of 45 (or even before the age of 40 if there is a family history of colorectal cancer) to rule out other possible causes of bleeding.
WHAT ARE THE MEDICATIONS FOR TREATING HEMORRHOIDS?
The basic therapy involves correcting the patient's dietary and physical habits. The diet should include increased fiber intake (fruits, vegetables, bran, grains) and liquids. Maintaining regular physical activity is recommended. These simple measures reduce stool consistency, thereby reducing straining during defecation. Warm sitz baths (sitting in warm water for 10 minutes three times a day) are helpful, inducing significant sphincter relaxation. When these measures are insufficient, medical therapy includes the use of bulk-forming agents that reduce stool consistency through an osmotic effect.
Laxatives are often contraindicated and should be administered only in selected cases. Many ointments and creams available on the market aim to treat local inflammation and hemorrhoidal congestion. They provide temporary relief and are often highly effective. If used for extended periods, it is advisable to prefer creams without cortisone or local anesthetics as prolonged use can lead to local hypersensitivity, resulting in dermatitis with burning, itching, and pain. For oral administration, highly effective medications are available to reduce bleeding and hemorrhoidal swelling, especially during acute phases.
IF MEDICAL TREATMENT FAILS, WHAT ARE THE SURGICAL REMEDIES?
Acute hemorrhoidal thrombosis can be resolved in an outpatient setting through a surgical incision of the anal swelling under local anesthesia. The benefit is immediate, as the blood clot is removed, and the patient experiences immediate relief. Surgical treatment varies depending on the grade of hemorrhoids. If they are Grade I and II (internal), they can be treated in multiple sessions in an outpatient setting using rubber band ligation. This method is not painful, and the patient can immediately return to work. However, it is not a definitive method, and recurrences are common. Another non-invasive method, performed on an outpatient basis, is sclerotherapy, where a particular substance is injected into the hemorrhoid to induce sclerosis. This method can be combined with rubber band ligation. Similar to rubber band ligation, this method is not definitive, and recurrences are common.
Cryotherapy (sclerosis of the hemorrhoid through cold), once commonly used, has now been largely abandoned. When hemorrhoids are Grade III or IV, with significant rectal mucosal prolapse, hospitalization is required. The "stapled hemorrhoidopexy according to Longo" involves using a circular stapler (a mechanical stapler that cuts and sutures simultaneously). Depending on the extent of prolapse, two staplers can be used. In this method, hemorrhoids are not removed but repositioned at the end of the rectum, in their original location.
By removing an excess cylinder of rectal wall that was causing the hemorrhoidal plexus to prolapse downward, normal anatomical conditions are restored. At the end of the surgery, there is a suture made of titanium staples in the rectum, which is almost completely devoid of painful sensitivity. For this reason, postoperative pain is minimal or absent. The results are excellent if the patient has been well selected (for more information, visit www.siucp.org).
"Hemorrhoidal dearterialization" (THD) involves locating the arterial branches of the hemorrhoids using a small Doppler probe, tying them off, and subsequently manually suspending the prolapsed rectal mucosa in six areas of the anorectal tract. Postoperative pain is almost entirely absent. The results of this method are promising, but longer follow-up is needed to establish recurrence rates over time. Techniques involving the removal of hemorrhoids can be categorized into traditional and recent approaches. Traditional methods include the Milligan-Morgan technique, which involves removing hemorrhoids while leaving the anal surgical wounds open, and the Ferguson technique, which removes hemorrhoids while closing the anal surgical wounds. There are also several variations that modify these two described techniques. Among the recent methods, there is hemorrhoid removal using radiofrequency devices (Ligasure).
WHAT ARE HEMORRHOIDS?
In the past, they were incorrectly referred to as "varicose veins of the anus and rectum." Hemorrhoids can be considered as clusters of vascular tissue (arterial and venous) located beneath the mucosa in the last section of the rectum, which play a role in the continence mechanism. To simplify, let's imagine lining the inside of a funnel with red velvet; the funnel represents the rectum, and the red velvet represents its mucosa. Now, let's imagine looking at our funnel from the inside, from top to bottom: at the end of the funnel (the rectum), beneath the red velvet lining (rectal mucosa), just before the neck (anal canal), there are cushions (hemorrhoids) that, like a diaphragm in a camera, collapse to prevent gas from escaping. Therefore, the hemorrhoidal plexus is present in all individuals. Hemorrhoidal disease is diagnosed when, for the reasons we will discuss, they become symptomatic.
WHAT ARE THE CAUSES OF HEMORRHOIDS?
The causes of hemorrhoidal disease are multiple. Hereditary factors are often implicated, but their high prevalence suggests other factors, such as constipation or diarrhea, excessive straining during bowel movements, a sedentary lifestyle, a diet lacking in fiber, and smoking. Less frequently, hemorrhoids can be an expression of more complex liver conditions (e.g., cirrhosis). Predisposing factors can include advanced age and pregnancy.
I'VE HEARD OF GRADE IV HEMORRHOIDS: WHAT ARE THEY?
To simplify, hemorrhoids can be classified into I, II, III, and IV grades. Grade I hemorrhoids are internal, located at the end of the rectum, and may bleed during or after defecation. They usually do not cause pain. If the rectal mucosa prolapses, sliding down into the anal canal, it brings the hemorrhoids along with it, and these are considered Grade II. If the prolapse extends beyond the anal canal, the hemorrhoids move outside of the anus but spontaneously retract or can be manually pushed back after a bowel movement (Grade III). When the prolapse of the rectal mucosa is more severe, the hemorrhoids remain constantly outside of the anus, regardless of bowel movements; in this case, they are referred to as Grade IV hemorrhoids.
WHAT ARE THE SYMPTOMS?
The symptoms depend on the grade of the hemorrhoids, or more precisely, the extent of prolapse. The most common symptom is bright red bleeding (hemorrhoids contain both arterial and venous blood) during defecation. Bleeding may persist for a few minutes after defecation and can be accompanied by anal burning, less frequently significant pain. Outside of defecation, during the day, symptoms depend on the extent of mucosal-hemorrhoidal prolapse (i.e., the degree of their "descent" into the anal canal or outside of the anus). Common symptoms include itching and soiling (small mucous leakage from the anus with a feeling of anal wetness). Hemorrhoids can also manifest acutely with intense pain and the appearance of swelling that can affect the entire anus or a part of it. The patient may feel a very painful, dark-colored hard lump that can also grow to significant sizes. The blood clot that forms within this swelling gives it the characteristic dark color. This condition is referred to as acute hemorrhoidal thrombosis and always causes pain for the patient.
HOW ARE HEMORRHOIDS DIAGNOSED?
A medical history and an anoscopy are sufficient to make the diagnosis. However, since hemorrhoid symptoms are similar to those of more serious conditions, it's a good practice to undergo a traditional or virtual colonoscopy after the age of 45 (or even before the age of 40 if there is a family history of colorectal cancer) to rule out other possible causes of bleeding.
WHAT ARE THE MEDICATIONS FOR TREATING HEMORRHOIDS?
The basic therapy involves correcting the patient's dietary and physical habits. The diet should include increased fiber intake (fruits, vegetables, bran, grains) and liquids. Maintaining regular physical activity is recommended. These simple measures reduce stool consistency, thereby reducing straining during defecation. Warm sitz baths (sitting in warm water for 10 minutes three times a day) are helpful, inducing significant sphincter relaxation. When these measures are insufficient, medical therapy includes the use of bulk-forming agents that reduce stool consistency through an osmotic effect.
Laxatives are often contraindicated and should be administered only in selected cases. Many ointments and creams available on the market aim to treat local inflammation and hemorrhoidal congestion. They provide temporary relief and are often highly effective. If used for extended periods, it is advisable to prefer creams without cortisone or local anesthetics as prolonged use can lead to local hypersensitivity, resulting in dermatitis with burning, itching, and pain. For oral administration, highly effective medications are available to reduce bleeding and hemorrhoidal swelling, especially during acute phases.
IF MEDICAL TREATMENT FAILS, WHAT ARE THE SURGICAL REMEDIES?
Acute hemorrhoidal thrombosis can be resolved in an outpatient setting through a surgical incision of the anal swelling under local anesthesia. The benefit is immediate, as the blood clot is removed, and the patient experiences immediate relief. Surgical treatment varies depending on the grade of hemorrhoids. If they are Grade I and II (internal), they can be treated in multiple sessions in an outpatient setting using rubber band ligation. This method is not painful, and the patient can immediately return to work. However, it is not a definitive method, and recurrences are common. Another non-invasive method, performed on an outpatient basis, is sclerotherapy, where a particular substance is injected into the hemorrhoid to induce sclerosis. This method can be combined with rubber band ligation. Similar to rubber band ligation, this method is not definitive, and recurrences are common.
Cryotherapy (sclerosis of the hemorrhoid through cold), once commonly used, has now been largely abandoned. When hemorrhoids are Grade III or IV, with significant rectal mucosal prolapse, hospitalization is required. The "stapled hemorrhoidopexy according to Longo" involves using a circular stapler (a mechanical stapler that cuts and sutures simultaneously). Depending on the extent of prolapse, two staplers can be used. In this method, hemorrhoids are not removed but repositioned at the end of the rectum, in their original location.
By removing an excess cylinder of rectal wall that was causing the hemorrhoidal plexus to prolapse downward, normal anatomical conditions are restored. At the end of the surgery, there is a suture made of titanium staples in the rectum, which is almost completely devoid of painful sensitivity. For this reason, postoperative pain is minimal or absent. The results are excellent if the patient has been well selected (for more information, visit www.siucp.org).
"Hemorrhoidal dearterialization" (THD) involves locating the arterial branches of the hemorrhoids using a small Doppler probe, tying them off, and subsequently manually suspending the prolapsed rectal mucosa in six areas of the anorectal tract. Postoperative pain is almost entirely absent. The results of this method are promising, but longer follow-up is needed to establish recurrence rates over time. Techniques involving the removal of hemorrhoids can be categorized into traditional and recent approaches. Traditional methods include the Milligan-Morgan technique, which involves removing hemorrhoids while leaving the anal surgical wounds open, and the Ferguson technique, which removes hemorrhoids while closing the anal surgical wounds. There are also several variations that modify these two described techniques. Among the recent methods, there is hemorrhoid removal using radiofrequency devices (Ligasure).