External Hemorrhoid


Article Author:
Aaron Lawrence


Article Editor:
Emily McLaren


Editors In Chief:
Sherri Murrell


Managing Editors:
Avais Raja
Orawan Chaigasame
Khalid Alsayouri
Kyle Blair
Radia Jamil
Erin Hughes
Patrick Le
Anoosh Zafar Gondal
Saad Nazir
William Gossman
Hassam Zulfiqar
Navid Mahabadi
Hussain Sajjad
Steve Bhimji
Muhammad Hashmi
John Shell
Matthew Varacallo
Heba Mahdy
Ahmad Malik
Abbey Smiley
Sarosh Vaqar
Mark Pellegrini
James Hughes
Beenish Sohail
Hajira Basit
Phillip Hynes
Sandeep Sekhon


Updated:
5/4/2019 2:56:39 PM

Introduction

Hemorrhoid disease is a common pathology that can yield symptoms ranging from minimal discomfort or inconvenience to excruciating pain and significant psychosocial implications. Conservative measures are considered first-line, and a primary care physician can initiate these. Patient education is paramount. Persistent or severe hemorrhoid disease can be managed by a colorectal surgeon who has numerous modalities at their disposal. These range from minimally invasive procedures to surgical hemorrhoidectomies.[1][2][3]

Etiology

Pathologic hemorrhoids are a result of increased pressure gradient within the hemorrhoid plexus. This typically results from increased intra-abdominal pressure experienced in scenarios such as prolonged straining during defecation or during pregnancy and labor. Not surprisingly, a history of chronic hard stool can precipitate hemorrhoid disease.[4][5]

Epidemiology

Hemorrhoid disease is a common anorectal disorder, affecting millions in the United States, and the most common cause of rectal bleeding. Hemorrhoids are believed to affect men and women equally. They are rare under 20 years of age, and incidence peaks between the ages of 45 and 65 years of age. Estimates of hemorrhoid disease in pregnant women vary, but range as high as 35%.

Pathophysiology

Hemorrhoids are cushions of submucosal tissue that are located within the anal canal. These structures cushion the anal canal and also support the anal canal lining. They are thought to aid in the complete closure of the anal canal at rest and to function as part of the body’s innate continence mechanism.

Increased intra-abdominal pressure, such as that associated with straining, passing hard stools, or childbirth yields venous engorgement of the hemorrhoid plexus. Bleeding, thrombosis, and prolapse can follow.

Histopathology

By definition, internal hemorrhoids occur proximal to the dentate line and are covered by anorectal mucosa that is insensate. External hemorrhoids occur distal to the dentate line and are covered by richly innervated anoderm. As such, internal hemorrhoids are classically considered relatively painless, while external hemorrhoids can yield very significant pain.

History and Physical

Typical complaints associated with hemorrhoid disease include pain, bleeding, pruritis, burning, and swelling. Patients may describe bright red blood dripping into the toilet. Hemorrhoids are the most common cause of rectal bleeding.

Evaluation

A physical exam can be accomplished with the patient in the prone jackknife position or left lateral decubitis. Buttocks must be distracted for visual examination which can readily identify many hemorrhoids, as well as other pathologies such as anal fissure, rectal prolapse, and fistulas. The digital exam is accomplished with a gloved and well-lubricated finger and can aid in excluding other palpable etiologies. Lastly, anoscopy can be performed, and patients may be asked to bear down, to simulate the increased intra-abdominal pressure associated with defecation. In complicated cases, or when a patient has difficulty tolerating an exam in a clinical setting, colorectal surgeons may sometimes opt to perform an exam in the operating room under anesthesia.

Treatment / Management

Conservative therapy is considered first-line treatment for symptomatic hemorrhoids. This includes increased dietary fiber, stool softeners, and increased water intake. Of note, the fiber must be accompanied by adequate water intake to ensure that stool is not just bulky, but also soft. Polyethylene glycol is an osmotic laxative that softens stool by increasing the water content of stool. Docusate is an anionic surfactant that promotes water and lipid entry into the stool, thereby softening it. These conservative medical measures can decrease straining and the sheering pressure associated with passing stool. This alleviates congestion and allows hemorrhoid cushions to return to their natural, non-pathologic state.

Rubber band ligation is a minimally invasive treatment option for first, second, and some third-degree internal hemorrhoids that do not respond to conservative therapy. Other minimally invasive options include sclerotherapy and infrared photocoagulation.[6][7][8][9][10]

The persistent or severe disease can be managed operatively, with surgical hemorrhoidectomy. In otherwise healthy patients, hemorrhoidectomies can be performed as "same day" surgeries. Post-operative pain is typically managed with oral narcotics, NSAIDs, and sitz baths.

Differential Diagnosis

When considering hemorrhoid disease as a diagnosis, one must give specific consideration to other potential anorectal pathologies. For example, anal fissures occur in the lower portion of the anal canal and typically yield pain and bleeding, worse with defecation. Anorectal abscesses can yield severe rectal pain, and sometimes a palpable mass. These have the potential to result in life-threatening sepsis. Although rather uncommon, anal prolapse typically presents with pain during defecation, and the patient may report a palpable mass. Anal intercourse can result in proctitis that yields pain, bleeding, and even skin changes. Offending microbes include Chlamydia trachomatis, Neisseria gonorrhoeae, and Herpes simplex. Malignancy is a potential cause of blood per rectum that must be considered. If bleeding is obviously originating from hemorrhoid disease in a young, otherwise healthy patient, the complete colonic examination may be deferred in favor of close follow-up. Patients with a family history of cancer, or patients older than 49 years of age, should be scheduled for a routine colonoscopy.

Staging

Hemorrhoids are classified as internal or external based on their location relative to the dentate line. External hemorrhoids occur distal to the dentate line. Internal hemorrhoids occur proximal to the dentate line and are further categorized into 4 different grades. Grade I hemorrhoids prolapse beyond the dentate line upon straining. Grade II hemorrhoids prolapse through the anus upon straining, but spontaneously reduce, while grade III hemorrhoids prolapse through the anus upon straining and can only be reduced manually. Grade IV hemorrhoids have prolapsed through the anus and cannot be reduced.

Complications

The most common complication of operative hemorrhoidectomy is urinary retention, occurring in 30% to 50% of patients. Post-operative pain is typically significant and requires oral narcotics in addition to NSAIDs. Other potential complications include bleeding, infection, and loss of continence.

Postoperative and Rehabilitation Care

Post-operative pain associated with excisional hemorrhoidectomy is significant, and typically requires oral narcotics in addition to NSAIDs, muscle relaxants, and sitz baths. Persistent and worsening pain accompanied by fever may signal a necrotizing soft tissue infection.

Consultations

Initial management of hemorrhoid disease includes conservative care and patient education. A primary care physician can routinely initiate this treatment. The severe or persistent disease can be referred to a colorectal surgeon for evaluation and operative management if indicated.

Deterrence and Patient Education

Conservative therapy is considered first-line treatment for symptomatic hemorrhoids. This includes increased dietary fiber, stool softeners, and increased water intake. These modifications can decrease straining and the sheering pressure associated with passing stool. This alleviates congestion and allows hemorrhoid cushions to return to their natural, non-pathologic state.

Increased fiber intake can be helpful with symptomatic hemorrhoids, but must be accompanied by adequate water intake to ensure that stool is not just bulky, but also soft. Polyethylene glycol is an osmotic laxative that softens stool by increasing the water content of stool. Docusate is an anionic surfactant that promotes water and lipid entry into the stool softening it.

Enhancing Healthcare Team Outcomes

External hemorrhoids are managed by a mutlidisciplinary team that includes an emergency department physician, general surgeon, gastroenterologist and an internist. The primary care provider and nurse practitioner play a vital role in educating the patient on preventing these lesions.

Conservative therapy is considered first-line treatment for symptomatic hemorrhoids. This includes increased dietary fiber, stool softeners, and increased water intake.  Rubber band ligation is a minimally invasive treatment option for first, second, and some third-degree internal hemorrhoids that do not respond to conservative therapy. [11]Other minimally invasive options include sclerotherapy and infrared photocoagulation. While surgery is effective, the results are not optimal and recurrences are commonn. Many patients do have residual anorectal pain after surgery. [12]

 


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External Hemorrhoid - Questions

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A 38-year-old male presents to his primary care provider with a chief complaint of bright red blood per rectum. He has minimal anal pain but does relate anal pruritis. He anxiously explains, "Sometimes it feels like something is sticking out, but then it goes back in." After a history and physical exam, his provider has concern for hemorrhoid disease. Which of the following is true regarding internal hemorrhoids?



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Which is false about internal hemorrhoids?



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Which is not an absolute contraindication to excision of a thrombosed external hemorrhoid?



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At which location are hemorrhoids unlikely to be found?



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Which is a not a risk factor for hemorrhoids?



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Which of the following is not included in the initial treatment of uncomplicated external hemorrhoids?



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Which of the following is not a factor that promotes hemorrhoids?



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Which of the following is not an initial treatment of uncomplicated hemorrhoids?



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Gastrointestinal bleeding is a relatively common complaint within primary care as well as emergency medicine. Bleeding can range from minimal to life-threatening. What is the most common cause of lower gastrointestinal bleeding in individuals under 50 years of age?



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Which of the following statements regarding hemorrhoids is false?



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A 40-year-old female presents for evaluation of irritating external hemorrhoids which are not improving with increased fiber intake, increased water intake, and topical therapies. Which of the following is not recommended for treatment of her external hemorrhoids?



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External hemorrhoids are innervated by cutaneous nerves that are derived from which of the following structures?



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Which statement about thrombosed external hemorrhoids is false?



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A 36-year-old female presents complaining of acute rectal pain. She is anxious but agrees to a physical exam, which reveals a mass just adjacent to the anus. It has a purple hue and is exquisitely tender to palpation. Which of the following is most likely?



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A 32-year-old male presents to his primary care provider because he found bright red blood on his toilet paper after a bowel movement. After a thorough physical exam, his provider believes that hemorrhoidal disease is the most likely etiology. The patient is eager to begin treatment and asks for direction. Which of the following is the most appropriate initial treatment for hemorrhoids?



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A 28-year-old female is diagnosed with external hemorrhoids during a postpartum visit with her obstetrician. The birth was vaginal and without complication. The patient's obstetrician gives her verbal counseling as well as written recommendations for the initial treatment of her hemorrhoidal disease. Which of the following is not a recommended treatment?



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Hemorrhoids can be classified as internal or external, based on their anatomic location. Additionally, internal and external hemorrhoids are covered by different types of epithelium. Which anatomic structure delineates internal hemorrhoids from external?



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A 39-year-old male returns to the office to discuss management of a second-degree internal hemorrhoid that has failed to respond to conservative treatment. After a discussion of risks and benefits, sclerotherapy is decided upon for treatment. Which of the following would not be found in the sclerotherapy solution?



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A 41-year-old male undergoes rubber band ligation for a second-degree internal hemorrhoid. During the procedure, ligation inadvertently includes a portion of the internal sphincter. This is specifically associated with which of the following possible complications?



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Which of the following is not conservative therapy for symptomatic hemorrhoids?



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External Hemorrhoid - References

References

Idrees JJ,Clapp M,Brady JT,Stein SL,Reynolds HL,Steinhagen E, Evaluating the Accuracy of Hemorrhoids: Comparison Among Specialties and Symptoms. Diseases of the colon and rectum. 2019 Jan 8;     [PubMed]
Lohsiriwat V, Anorectal emergencies. World journal of gastroenterology. 2016 Jul 14;     [PubMed]
Mirhaidari SJ,Porter JA,Slezak FA, Thrombosed external hemorrhoids in pregnancy: a retrospective review of outcomes. International journal of colorectal disease. 2016 Aug;     [PubMed]
Hollingshead JR,Phillips RK, Haemorrhoids: modern diagnosis and treatment. Postgraduate medical journal. 2016 Jan;     [PubMed]
Lohsiriwat V, Treatment of hemorrhoids: A coloproctologist's view. World journal of gastroenterology. 2015 Aug 21;     [PubMed]
Hou CP,Lin YH,Hsieh MC,Chen CL,Chang PL,Huang YC,Tsui KH, Identifying the variables associated with pain during transrectal ultrasonography of the prostate. Patient preference and adherence. 2015;     [PubMed]
Tsang YP,Fok KL,Cheung YS,Li KW,Tang CN, Comparison of transanal haemorrhoidal dearterialisation and stapled haemorrhoidopexy in management of haemorrhoidal disease: a retrospective study and literature review. Techniques in coloproctology. 2014 Nov;     [PubMed]
Fox A,Tietze PH,Ramakrishnan K, Anorectal conditions: hemorrhoids. FP essentials. 2014 Apr;     [PubMed]
Jaiswal SS,Gupta D,Davera S, Stapled hemorrhoidopexy - Initial experience from a general surgery center. Medical journal, Armed Forces India. 2013 Apr;     [PubMed]
Chan KK,Arthur JD, External haemorrhoidal thrombosis: evidence for current management. Techniques in coloproctology. 2013 Feb;     [PubMed]
Hill A, Stapled haemorrhoidectomy--no pain, no gain? The New Zealand medical journal. 2004 Oct 8;     [PubMed]
Araujo SE,Horcel LA,Seid VE,Bertoncini AB,Klajner S, LONG TERM RESULTS AFTER STAPLED HEMORRHOIDOPEXY ALONE AND COMPLEMENTED BY EXCISIONAL HEMORRHOIDECTOMY: A RETROSPECTIVE COHORT STUDY. Arquivos brasileiros de cirurgia digestiva : ABCD = Brazilian archives of digestive surgery. 2016 Jul-Sep;     [PubMed]

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