Hemorrhoids have plagued humankind since time immemorial, yet many misunderstandings regarding hemorrhoidal complaints and disease still exist. Many laypersons and physicians do not understand the anorectal area and the common diseases associated with it.

The term hemorrhoid is usually related to symptoms caused by hemorrhoids. Hemorrhoids are present in healthy individuals. When these vascular cushions produce symptoms, most laypersons and physicians refer to them as hemorrhoids. Hemorrhoids generally cause symptoms when they become enlarged, inflamed, thrombosed, or prolapsed.

Low-fiber diets cause small-caliber stools, which result in straining with defecation. This increased pressure causes engorgement of the hemorrhoids, possibly by interfering with venous return. Pregnancy and abnormally high tension of the internal sphincter muscle can also cause hemorrhoidal problems, presumably by means of the same mechanism. Decreased venous return is thought of as the mechanism of action. Prolonged sitting on a toilet (eg, while reading) is believed to cause a relative venous return problem in the perianal area (a tourniquet effect), resulting in enlarged hemorrhoids. Aging causes weakening of the support structures, which facilitates prolapse. Weakening of support structures can occur as early as the third decade of life.

Straining and constipation have long been thought of as culprits in the formation of hemorrhoids. This may or may not be true. Patients who report hemorrhoids have a canal-resting tone that is higher than normal. Of interest, the resting tone is lower after hemorrhoidectomy than before. This change in the resting tone is the mechanism of action of Lord dilatation, which is most commonly performed in the United Kingdom.

Pregnancy clearly predisposes women to symptoms from hemorrhoids, although the etiology is unknown. Notably, most patients revert to their previously asymptomatic state after delivery. The relationship between pregnancy and hemorrhoids lends credence to hormonal changes or direct pressure as the culprit.

Portal hypertension has often been mentioned in conjunction with hemorrhoids. Hemorrhoidal symptoms do not occur more frequently in patients with portal hypertension than in those without. Massive bleeding from hemorrhoids in these patients is unusual. Bleeding is very often complicated by coagulopathy. If bleeding is found, direct suture ligation of the offending column is suggested.

Anorectal varices are common in patients with portal hypertension. Varices occur in the mid rectum, at connections between the portal system and the middle and inferior rectal veins. Varices occur more frequently in patients who are noncirrhotic, and they rarely bleed. Treatment is usually directed at the underlying portal hypertension. Emergent control of bleeding can be obtained with suture ligation. Portosystemic shunts and, more recently, transjugular intrahepatic portosystemic shunts (TIPS) have been used to control hypertension and, thus, the bleeding.

Treatment is divided by the cause of symptom into internal and external treatments. Internal hemorrhoids do not have cutaneous innervation and thus can be destroyed without anesthetic. Internal hemorrhoids are classified by symptom. Grade I hemorrhoids only bleed. Grade II hemorrhoids prolapse and reduce spontaneously. Grade III hemorrhoids require manual replacement, and grade IV hemorrhoids are permanently prolapsed.

Because most physicians believe that straining and a low-fiber diet cause hemorrhoidal disease, conservative treatment includes increasing fiber and liquid intake and retraining in toilet habit. Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, first-line treatment for all first- and second-degree (and many third- and fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation.

Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, have a small role in the treatment of hemorrhoidal symptoms. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. The author rarely recommends typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. ubmucosal veins do not get smaller with anti-inflammatory medications.

Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. The author does not suggest mechanisms such as the sitz bath for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role with older patients and with immobile patients who cannot routinely get in and out of a bathtub.

Numerous methods to destroy internal hemorrhoids are available; these includes rubber-band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, carbon dioxide freezing, Lord dilatation, stapled hemorrhoidectomy, and surgical resection. All of these methods (except stapled hemorrhoidectomy and surgical resection) are considered nonoperative treatments and should be the first-line of treatment for all grade I and grade II hemorrhoids that do not respond to conservative therapy.

Sclerotherapy can provide adequate treatment for early internal hemorrhoids. Cryotherapy and sclerotherapy are infrequently used today. Most experienced surgeons use 1 or 2 techniques exclusively.

Symptoms have historically been treated with dietary modifications, incantations, voodoo, quackery, and application of a hot poker. Molten lead has also been described as a treatment. The adverse effects of these treatments have a direct relationship to whether patients relay persistent or recurrent complaints to the physician or return for further treatment.

Surgical therapy : Operative resection is reserved for patients with grade III and grade IV hemorrhoids, patients who fail nonoperative therapy, and patients who also have significant symptoms from external hemorrhoids or skin tags. Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, one prospective study found no difference between scalpel and laser hemorrhoidectomy. The reader is referred to appropriate textbooks to see descriptions of techniques used.