![]() Rubber band ligation is considered the preferred choice in the office-based treatment of grades I to III hemorrhoids because of effectiveness compared with other office-based procedures.Įxcisional (conventional) hemorrhoidectomy is effective for the treatment of grade III or IV, recurrent, or highly symptomatic hemorrhoids. Most patients who undergo excision of thrombosed hemorrhoids within two to three days of symptom onset achieve symptom relief. Increasing fiber intake is an effective first-line, non-surgical treatment for hemorrhoids. This grading system is incomplete, however, because it focuses exclusively on the extent of prolapse and does not consider other clinical factors, such as size and number of hemorrhoids, amount of pain and bleeding, and patient comorbidities and preferences. ![]() The extent of prolapse of internal hemorrhoids can be graded on a scale from I to IV, which guides effective treatment ( Figure 2). External hemorrhoids develop below the dentate line and can become painful when swollen. They are painless because they are viscerally innervated. 2 Hemorrhoids developing above the dentate line are internal. The anus is approximately 4 cm long in adults, with the dentate line located roughly at the midpoint. Hemorrhoids occur above or below the dentate line where the proximal columnar transitions to the distal squamous epithelium ( Figure 1 1 ). However, the exact pathophysiology is unknown. Hemorrhoids develop when the venous drainage of the anus is altered, causing the venous plexus and connecting tissue to dilate, creating an outgrowth of anal mucosa from the rectal wall. Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms. Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly. Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue however, this procedure has several potential postoperative complications. Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain. Open or closed (conventional) excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures therefore, hemorrhoidectomy should be reserved for recurrent or higher-grade disease. If these are unsuccessful, office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step because it has a lower failure rate than infrared photocoagulation. Medical management (e.g., stool softeners, topical over-the-counter preparations, topical nitroglycerine), dietary modifications (e.g., increased fiber and water intake), and behavioral therapies (sitz baths) are the mainstays of initial therapy. Other factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued. ![]() Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse. The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes. ![]() Hemorrhoidal size, thrombosis, and location (i.e., proximal or distal to the dentate line) determine the extent of pain or discomfort. Many Americans between 45 and 65 years of age experience hemorrhoids.
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