How to treat haemorrhoids

Haemorrhoids and their symptoms are one of the most common afflictions in the Western world.^1–4 They can occur at any age and can affect both women and men. Because the presence of haemorrhoidal tissue is normal—it acts as a compressible lining which allows the anus to close completely—disease should be thought of as haemorrhoidal tissue that causes significant symptoms.¹,² Unfortunately, haemorrhoids tend to get worse over time, and disease should be treated as soon as it occurs.

Haemorrhoids cushion sinusoids, and bleeding occurs from presinusoidal arterioles.² The main cushions lie at the left lateral, right anterolateral, and right posterolateral portions of the anal canal. Secondary cushions may be present. Proposed aetiological factors include constipation, prolonged straining, derangement of the internal anal sphincter, and pregnancy. Haemorrhoids may be caused by more than one factor. Despite being examined in several studies, the pathogenesis remains unclear.¹,² Haemorrhoids can be either internal or external, and patients may have both types.^1–4 External haemorrhoids occur below the dentate line and are generally painful. When inflamed they become red and tender, and if they become thrombosed they can cause severe pain and be felt as a tender mass in the anal area. Internal haemorrhoids are located proximal to the dentate line and are usually painless. If they protrude into but do not prolapse out of the anal canal they are classed as grade I; if they prolapse on defecation but spontaneously reduce they are grade II; haemorrhoids that require manual reduction are grade III; and if they cannot be reduced they are grade IV. Haemorrhoids that remain prolapsed may develop thrombosis and gangrene.¹

Symptoms of haemorrhoids can include bleeding, mucosal or faecal soiling, itching, and occasionally pain. The diagnosis is made by examining the anus and anal canal, and it is important to exclude more serious causes of bleeding, such as colorectal cancer. No relation between haemorrhoids and cancer has been found.

The best treatment is prevention. A diet high in fibre and bulk can prevent constipation. If the diet cannot be modified in this way, adding bulk laxatives may be necessary; they can prevent worsening of the condition. There are numerous creams and suppositories that can relieve anal irritation and pain, but they rarely provide long term benefit.

For patients with grade I or grade II haemorrhoids or who have larger haemorrhoids but wish to avoid surgical treatment, outpatient procedures, such as sclerotherapy, photocoagulation, rubber band ligation, and cryotherapy, may be appropriate.^1–4 An ulcer forms above the haemorrhoidal tissue after each of these treatments. As the wound heals, fibrosis results in mucosal fixation.² It is thus essential that local treatments be applied to the mucosa above the haemorrhoids; if applied too low, they may cause excessive pain. Rubber band treatment works effectively on internal haemorrhoids that protrude during defecation. The procedure sometimes produces mild discomfort and bleeding, but it is generally the treatment of choice for patients who have haemorrhoids and for whom haemorrhoidectomy is considered too radical, or when the patient specifically wishes to avoid surgical excision.³

Excessive activity of the internal anal sphincter is often associated with bleeding; for such patients gentle anal dilatation under general anaesthesia is advisable.³ It is important to recognise that stretching the sphincter inevitably attenuates the external sphincter as well as the internal¹; spasms of the internal sphincter may be relieved by injections of botulinum toxin or topical application of nitroglycerine ointment.⁵,⁶

If symptoms recur after topical treatment the patient can be treated with a further application, a different treatment may be applied topically, or haemorrhoidectomy may be considered for more definitive control of symptoms. Haemorrhoidectomy is necessary when clots repeatedly form in external haemorrhoids, ligation fails to treat internal haemorrhoids, the protruding haemorrhoid cannot be reduced, or there is persistent bleeding.¹,²,⁴ Haemorrhoidectomy is done under general anaesthesia and may require admission to hospital.

Several operative techniques have been described.¹,² Milligan-Morgan's open haemorrhoidectomy is most commonly used and is widely considered to be the most effective surgical technique for treating haemorrhoids.⁷ Other techniques, such as Ferguson's closed haemorrhoidectomy and Parks' submucosal haemorrhoidectomy, are technically more complex.

The surgeon's choice of technique is primarily based on personal experience and technical training, and only a competently performed technique produces satisfying results.¹,⁴,⁸ If technical guidelines are rigorously followed, the feared complications associated with surgical procedures, such as anal stricture and sphincteric injuries, are largely reduced.⁹ Furthermore, prophylactic metronidazole suppresses postoperative pain, increases patients' satisfaction, and allows them to return to work earlier.⁶ Laser haemorrhoidectomy has no advantages over standard techniques; it is also quite expensive and no less painful.¹

Studies suggest that stapled haemorrhoidectomy is an effective treatment, reducing postoperative pain, the length of hospital stay, and encouraging a rapid return to normal activities when compared with conventional haemorrhoidectomy.¹⁰,¹¹ This technique potentially provides a tool for reducing some of the complications associated with conventional surgery, provided that the operator has the technical experience. However, stapling increases operative costs; advanced surgical skills are necessary; and there is a learning curve.¹² Stapled haemorrhoidectomy may cause a full thickness excision of the rectal wall and injuries to the anal sphincter, and it does not allow for the treatment of concomitant anal disease.