Introduction

“I’m sitting on top of the world . . .and I’ve got hemorrhoids!” Rodney Dangerfield (1921-2004)

Patients commonly present to their gastroenterologist with symptomatic hemorrhoids and other anorectal issues. These patients, as well as their referring physicians, have an expectation that the gastroenterologist will be able to effectively treat these problems. Unfortunately, most gastroenterology fellowship programs do not include the care of these issues within the fellows’ training [1], and in fact, techniques such as anoscopy and hemorrhoid care are not included in the Gastroenterology Core Curriculum [2]. This very often leads to the referral of these patients to surgical specialists or patients are left untreated.

The gastroenterologist is uniquely situated to care for these issues, and in doing so, provide for a continuum of care in a very cost-effective manner [3]. This paper’s aim is to introduce the diagnosis and non-surgical therapeutic options available for these patients.

Hemorrhoid disease is not a recent development. Topical treatment of hemorrhoids was mentioned in Egyptian writings from 1700 BC, and the first report of a surgical treatment (a hemorrhoidopexy of sorts) was included in the Hippocratic Treatises of 460 BC [4, 5]. There are biblical references to hemorrhoids as well [6].

There is even a Patron Saint of Hemorrhoids! Fiacre, an Irish Catholic monk in the seventh century, was said to have developed a severe case of prolapsed hemorrhoids. He sat on a stone and prayed, and the hemorrhoids vanished, leaving their imprint on the stone. Legend has it that a hemorrhoid sufferer who sits on the stone and prays will have their hemorrhoids cured. (It is my understanding that the use of the stone has not been cleared by the FDA or EMA). Saint Fiacre is also the Patron Saint of vegetable growers, Parisian cab drivers, fistulas, and even venereal diseases [7, 8].

Epidemiology

“I was watching a commercial the other day, and they said that 8 out of 10 people suffer from hemorrhoids! What? Do the other 2 enjoy them? (Robert Schimmel 1950 - 2010)

The precise incidence of symptomatic hemorrhoids is difficult to discern, as many people with symptomatic hemorrhoids do not seek medical care, and many others wrongly attribute symptoms to one or more other anorectal issues as being due to hemorrhoids [3]. Estimates of the prevalence rate vary widely, with numbers quoted from 4.4% in one study [9], to a National Center of Health Statistics report of up to 12.8% [10], and yet others reporting up to a 40% prevalence rate [11, 12].

Other popularly cited statistics include the points that developing symptoms before the age of 20 is unusual, the peak incidence tends to occur between the ages of 45–65 years, and the risk is greater in Caucasians than in African Americans [9, 13]. It has also been stated that 75% of Americans will experience hemorrhoid symptoms at some point in their lifetime [14]. In 2004, the NIH noted that the diagnosis of “hemorrhoids” was associated with 3.2 million ambulatory care visits, 306,000 hospitalizations and 2 million prescriptions in the USA [15], and in 2012, the term “hemorrhoid” was the most popular healthcare-related search with statistics provided by Google [16].

Anatomy and Physiology

“One poll showed that Americans have a higher opinion of witches, the IRS, and hemorrhoids than Congress.” Senator Tom Coburn, OK

The rectum, which extends from its junction with the sigmoid colon to its junction with the anus, is lined by a relatively insensate mucosa with a columnar epithelium. The anus is lined by a very sensitive squamous epithelium referred to as the anoderm. The epithelial junction of the two structures is called the “dentate line,” which is 2–3 cm from the anal verge. The anal canal is approximately 4 cm in length, extending from the anal verge to a point at the proximal aspect of the levator-sphincteric complex [17] (Fig. 1).

Fig. 1
figure 1

Normal anatomy of anorectrum. Courtesy of Iain Cleator MD and CRH Medical, Vancouver, BC

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Internal hemorrhoids are “cushions” of fibrovascular tissue that are covered by columnar epithelium and are thus proximal to the “dentate line” (as opposed to external hemorrhoids, which are covered by squamous epithelium and therefore are distal to the dentate line). There are typically three major internal hemorrhoidal “cushions,” located in the right anterior, right posterior, and left lateral positions; although, significant variations in their positions are common. These cushions include a rich vascular network of arteriovenous anastomoses, somewhat resembling erectile tissue, and are secured by muscular fibers which pass through the internal sphincter. They are supplied by branches of the superior and middle hemorrhoidal arteries and drained by branches of the superior, middle, and inferior hemorrhoidal veins with some contribution from the inferior hemorrhoidal artery [18, 19].

The hemorrhoidal cushions are felt to play an important role in maintaining continence, as they provide 15–20% of the resting closure pressure at the anal verge and may provide a protective function for the sphincter muscles. Due to the sinusoidal “erectile” nature of their vasculature, hemorrhoids also help to maintain anal closure when straining (Valsalva Maneuver) [20, 21].

Etiology and Pathophysiology of Hemorrhoid Disease

“Awards are like hemorrhoids. Sooner or later, every a**hole gets one.” Francois Ozon (French Film Director/Screenwriter)

While hemorrhoids are normally occurring structures, they typically are not referred to until problems arise—so the term “hemorrhoids” is used to refer to the “symptomatic and abnormally downward displacement of the anal cushions . . . .” [22] The true pathophysiology of hemorrhoid disease is not completely clear, but certainly seems to be multifactorial, including the sliding anal cushion (prolapse), hyperperfusion of the hemorrhoidal vasculature, inflammation of the tissue, and in some, redundancy of the rectum [22, 23•] (Fig. 2).

Fig. 2
figure 2

Grade II prolapsing internal hemorrhoid, external hemorrhoid. Courtesy of Iain Cleator MD and CRH Medical, Vancouver, BC

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The pathophysiology behind the development of hemorrhoidal symptoms seems to stem from the breakdown of the suspensory musculature of the cushions and their subsequent prolapse. Several risk factors for this breakdown have been described, including a lack of dietary fiber, straining, constipation, diarrhea, pregnancy, family history, and spending too long on the commode [24].

Prolapse of the hemorrhoidal cushions leads to various symptoms, including itching (from mucus deposition), bleeding, swelling, prolapse, and leakage [3]. Covered by insensitive mucosa, pain is not typically associated with internal hemorrhoids, so if pain is part of the patient’s presenting complaints, additional efforts are required to identify additional clinical problems. It should be noted that at least 20% of hemorrhoid sufferers also have symptomatic anal fissures [25], and these fissures require treatment in addition to the coexistent symptomatic hemorrhoids for the patient to see complete symptomatic relief [26].

Evaluation and Diagnosis

“One finger in the throat and one in the rectum makes a good diagnostician.” Sir William Osler (1849 – 1919)

History

As stated above, symptomatic hemorrhoids can cause several issues, but it should be kept in mind that there are many other entities which cause perianal symptoms that are wrongfully attributed to hemorrhoidal disease. “ . . . many other anorectal pathologies such as anal fissure, fistula, pruritus, condylomata, and even anal cancer are often labeled as “hemorrhoids” by the lay person.” [27].

For the above reasons, the authors tend to take much of the patient history with a large “grain of salt”, and subsequent management depends more on their physical examination.

Physical Examination

“It was not an examination . . . it was a COURTSHIP!” Dennis Wolfberg (1946 – 1994)

There are several components to the proper physical examination of the patient complaining of hemorrhoids or most any anorectal complaint. These include the visual examination, the digital anorectal exam, and one of several available endoscopic options.

Visual Examination

A visual examination may be performed in the “jack-knife” or left lateral decubitus positions. We prefer the left lateral position, as it seems to be more comfortable (and less intimidating) for the patient [28]. Inspection of the perianal, perineal, and pilonidal areas may reveal skin lesions, abscesses, rashes, fistulous tracts, pilonidal disease, external hemorrhoids, etc. [29, 30].

Digital Anorectal Examination

From experience, many clinicians are never taught how to do a proper digital rectal examination (DRE), and some believe that this part of the exam is not necessary if an endoscopic examination (flexible sigmoidoscopy or colonoscopy) is planned. In our opinion, a good DRE is crucial in the evaluation of patients with anorectal or perianal complaints, and the key to a good rectal examination is an understanding that this is an examination of the anus as much as it is an exam of the rectum.

In addition to being able to evaluate sphincter tone and function, evidence of small abscesses and other intra-anal lesions, such as the remnants of partially healed fissures and the origins of fistulae, can be easily palpated during the anal portion of the exam. Partially healed fissures may not be terribly tender, often are not be easily visualized, and may be noted as an area of thickening, scarring, or a rough area of the anoderm surrounded by normal tissue. These should be diagnosed on a clinical basis [31]. Again, experience teaches us that failure to diagnose and subsequently treat some of these partially healed fissures is commonly the explanation for a treatment failure for a patient with “hemorrhoids.”

Endoscopic Examination

The anoscope is an excellent instrument with which to examine the introitus and distal rectum. The exam can be quickly performed at the bedside, without sedation or prep, using very inexpensive, disposable, self-lighted instruments. All too often the flexible endoscope is utilized to evaluate the anorectum, but unfortunately, these techniques are less accurate than simple anoscopy. Kelly’s work prospectively demonstrated anoscopy’s 99% accuracy in detecting anorectal issues, where the flexible endoscope in retroflexion found only 54% of those same issues [32•].

Insufflation will mask many patients’ internal hemorrhoids, as the intraluminal pressure and “stretch” of the rectum will “flatten” out the internal hemorrhoids, making them more difficult to see, and the physical presence of the endoscope in the anal canal will block the visibility of small fissures and other potential findings. There are some maneuvers that can be utilized to increase the diagnostic yield of a flexible endoscope [33], such as partially deflating the rectum in order to help visualize the hemorrhoidal columns as well as using the “puddle test” where irrigant is pumped into the anorectal area, creating a puddle. The patient is in the left lateral position, so the puddle identifies the left side, and so the left lateral hemorrhoid... then, using this as a reference, the other hemorrhoids can be identified [34•]. Even so, the “gold standard” for the endoscopic evaluation of the anus remains the anoscope.

It should be emphasized that anoscopy is in no way suggested to be a substitute for the flexible endoscope when the remainder of the colon and rectum are concerned—only that the anoscope is crucial to the evaluation of the anal canal and distal rectum.

Miscellaneous Diagnostic Techniques

In our experience, it is common to encounter patients complaining of one or more perianal complaints, describing what sounds like prolapse, or some other change in their perianal area that is not obvious at the time of their examination. Obviously, what happens when you ask a patient to strain while on your exam table is much different from what happens when the patient is on the commode, so demonstrating the patient’s problem can be quite challenging in the office setting. Asking the patient to use the rest room in your office may help, but this technique fails as often as it succeeds, as do other evaluations such as defecography.

We have had great success with an examination technique that we have termed the “butt selfie”. When the patient’s intermittent problem recurs, the production of an image can facilitate the diagnosis, particularly of early rectal prolapse, which may not be not severe enough to show itself on physical examination. We have had a number of patients in whom we cannot demonstrate their pathology in our office, so when their issue does recur later, this image helps us to confirm their diagnosis.

Classification (Grading) of Hemorrhoids

As stated earlier, “internal hemorrhoids” denotes hemorrhoidal tissue covered by columnar epithelium (above the dentate line) and “external hemorrhoids” represents hemorrhoidal tissue covered by squamous epithelium (below the dentate line). These terms can be confusing as there are “external” hemorrhoids “inside” the anal verge. Banov [35] went on to further classify internal hemorrhoids as follows:

  • Grade I—do not prolapse during defecation—may cause painless bleeding

  • Grade II—prolapse during defecation and spontaneously reduce

  • Grade III—prolapse during defecation and must be manually reduced

  • Grade IV—hemorrhoids are incarcerated, not reducible

Most the patients that we will see in an office setting have grade II and/or III internal hemorrhoids. Patients with grade IV internal hemorrhoids are more likely to go to the emergency room due to the severity of their symptoms and grade I patients only infrequently need treatment.

Treatment

“I saw a sign one time that said 'hemorrhoids awareness week' at the doctor's office. Let me tell you, if you got hemorrhoids, I'm sure you are aware of it. You don't need a sign to tell anybody about it.” Larry the Cable Guy

In this section, we will briefly review some of the varied treatment options available to symptomatic patients.

Conservative (“Medical”) Treatment

“Sir, this lane is for ten items or less. I’m counting thirteen items in your cart, including that hemorrhoid cream. And while hemorrhoids might give you a reason to be nasty, they don’t give you a reason to be in this lane.” J.A. Konrath

Diet and behavioral changes are typically recommended, and in many cases, these will improve or lessen the frequency of symptoms on their own. Fiber supplementation has allowed patients to defecate without straining if they are relatively constipated, and it serves to help others with their diarrhea, increasing the stool bulk and lessening the frequency of bowel movements. Reader’s Digest conducted a national poll and found that the bathroom was the most common site where the publication was read. Reducing the time spent on the commode and the amount of straining required will help some to minimize their symptoms or lessen their frequency [36].

While there are also innumerable over-the-counter medications available to treat hemorrhoids, it should be noted that there are no high-quality clinical trials to show any long-term benefit of these substances. In fact, prolonged use of some of these therapies may even have detrimental effects [37].

A possible exception surrounds the use of oral flavonoids. A recent meta-analysis suggested that these medications helped with pruritus, bleeding, post-hemorrhoidectomy bleeding, discharge, and provided general symptomatic improvement. The authors of the meta-analysis noted “methodological limitations” in a number of the studies and suggested “more robust clinical trials” to help confirm the above findings [38].

Non-surgical Treatments

Each of the following techniques attempts to correct the hemorrhoidal cushion prolapse by causing a re-fixation of the tissue to the underlying structures, as well as to decrease vascularity and to reduce some of the redundant tissue [27], and each technique has its strengths and weaknesses.

Sclerotherapy

Sclerotherapy is one of the oldest forms of non-operative intervention for hemorrhoids, first described by Morgan in 1869 [39]. The procedure involves the trans-anoscopic injection of a sclerosant into the submucosa of the hemorrhoid base, resulting in fibrosis and scarring. The technique is suitable for smaller hemorrhoids (typically grades I and II) and may be helpful in patients on anticoagulants. Complications occur when the sclerosant is injected too deeply, too superficially, or not far enough away from the dentate line, and include ulceration, pain, abscess, urinary symptoms, and even impotence [19, 20, 39].

Bipolar Diathermy, Heater Probe, Direct Current Electrotherapy

The bipolar and heater probes rely on the heat generated from the device to coagulate the treated tissue, with the expectation of having the subsequent scarring recreate the hemorrhoids’ fixation to the underlying tissue, eliminating hemorrhoid prolapse and symptoms. Studies have shown each to have similar efficacy, but bipolar use was associated with more post-treatment pain [40], and the need for more treatments than band ligation to control patients’ symptoms [41].

The Direct Current (DC) Probe (Ultroid ®), on the other hand, does not generate heat but rather NaOH is generated at the negative electrode of the device, achieving the desired results. This procedure is performed across the anoscope, and the device is held in place for a length of time dependent upon the grade of the hemorrhoid and the patients’ tolerance of the current to be used, up to 16 min for a grade III hemorrhoid [42, 43].

Infrared Coagulation

Infrared coagulation (IRC) was first described by Neiger in 1979 [44]. The heat generated by the infrared light coagulates tissue at the apex of the hemorrhoid, and its primary benefit is in the treatment of smaller hemorrhoids [30]. IRC is generally well tolerated, but it has been found to be less effective than rubber band ligation (RBL), and typically requires more treatments than RBL; although, IRC has been shown to cause less post-procedural pain or complications [45].

Cryotherapy and “Lord’s Procedure”

These two techniques are grouped together only to dismiss both. Cryosurgery is accompanied by significant pain and foul-smelling discharge along with a more prolonged recovery [19, 39], and “Lord’s Procedure” involves the manual dilatation of the anus to counter the sphincter spasm that often accompanies hemorrhoid symptoms. The procedure has fallen into disfavor in the USA, as there are a significant number of these patients that will develop incontinence afterwards [46, 47].

Rubber Band Ligation

Ligation of internal hemorrhoids was first described by Blaisdell in 1958, using suture material [48], and then Barron reported on the ligation of hemorrhoids using rubber bands in 1963 [49]. The band will cause the entrapped tissue to necrose and slough, with the ultimate goal being the production of inflammation and the re-fixation of the hemorrhoidal cushion where it belongs, eliminating the prolapse and hemorrhoidal symptoms [20, 39,40,41,42,43,44,45,46,47,48,49,50]. Barron suggested banding a single hemorrhoidal cushion per session in order to minimize the complications of the banding. Others have challenged that assertion, stating that the additional complications encountered by banding all of the hemorrhoids at a single session are justified by the lesser number of patient treatments. We disagree with this, as one of the most frequently cited studies supporting multiple bandings found nearly ten times more complications in patients with multiple vs single hemorrhoids treated at the same session [51].

Since its original introduction, rubber band ligation (RBL) has become the most common non-surgical procedure for hemorrhoids, being utilized for up to 80% of patients [52], and there are a number of techniques with which to place the band. There are endoscopic techniques, along with several trans-anoscopic approaches, and the transanal approach which uses a blind “touch” technique. The endoscopic approach is clearly the most expensive and cumbersome for the patient, with the endoscopic prep and costs added onto a costlier banding device, and the various techniques utilized in the office may require wall suction, an anoscope, and/or a second person to perform the procedure [53, 54].

RBL has been shown to have superior long-term results, requiring fewer treatments than other non-surgical options, the main issue being post-banding pain [45, 55]. Post-banding pain statistics vary widely, as studies have shown significant pain rates from 1% [56] to as high as 50% [57]. Technical factors that seem to increase the risk of complications with RBL include the passage of an anoscope [58] and the number of bands placed [51].

Another factor that seems a bit more difficult to assess is the location of the band. Reviewing the literature, recommendations are often quite inexact, stating that the band should be placed “above the dentate line”. Dr. Cleator specifies that the band should be at least 2 cm proximal to the dentate line, and he reports less than 1% of his patients having significant post-banding pain. For those patients that do exhibit pain after band deployment, he follows up by mobilizing the band proximally. This more proximal placement seems to avoid the bulk of the complications reported by others, but does not sacrifice results as he reported a 5% recurrence rate at 2 years and a 13% recurrence rate at 42 months [56, 59]. So, using a blind “touch” technique, banding one column of hemorrhoids at a setting, and placing the band at least 2 cm proximal to the dentate line seem to be the factors which allow for a successful banding without undue risk of pain or other complications.

RBL is indicated for the treatment of grades I–III disease [60], acknowledging that surgery is more effective in treating grade III hemorrhoids than is RBL [61]. The low rates of post-operative pain and morbidity makes it well worth the effort of performing RBL, with those who do not respond referred on for surgical intervention.

Contraindications to RBL are somewhat controversial, with several mixed messages in the literature. Contraindications listed include anticoagulation, cirrhosis/portal hypertension, pregnancy, and any inflammatory process in the colon. That being stated, Dr. Cleator has reported banding 150 times on warfarin, with only one post-banding bleed, and that not coming from the banding site but rather from a coexistent fissure.

Nelson noted that the most frequent time for bleeding after a band ligation was in the 5–10-day range and suggested for those patients in whom anticoagulation is to be discontinued that the meds should be held starting on the day of the procedure and for 7 days for warfarin/10 days for antiplatelet medications. He also rightly noted that there are risks in withholding these medications, and the risk of bleeding must be weighed against the risk of MI, CVA, etc. [62].

Another commonly stated contraindication would be for a patient with cirrhosis or portal hypertension, but there have been authors disputing this (although with small sample sizes) [63].

Surgery

“Hemorrhoid? That looks more like a hand grenade!” Roger Sherman, MD (1924-2006) after walking in on a resident performing a hemorrhoidectomy on a patient with grade IV disease.

A discussion of the surgical options for hemorrhoid sufferers is beyond the scope of this paper, but mention of the indications for surgical consultation seems warranted. Surgery is indicated in patients that cannot tolerate an office-based procedure, those who fail non-surgical treatment, and most patients with grade IV hemorrhoids. Our own experience shows that only 1–2% of our hemorrhoid patients need to proceed to surgery [59].