OTHER ANORECTAL CONDITIONS

Diet and defecation habits little evidence exists to support

the widely held beliefs that inadequate intake of fibre, prolonged
sitting on the toilet and straining lead to the development of
symptomatic haemorrhoids. Fibre intake and the prevalence of
haemorrhoids are not associated. There has not been an overall
increase in fibre intake among western populations despite a fall
in the prevalence of haemorrhoids.

Haemorrhoids
Caron S Parsons MRCS
John H Scholefield FRCS

Pathogenesis
The varicose vein theory stems from the assumption that the
discrete venous dilations within haemorrhoids occur as a result of
pathological change. These were thought to be a result of increased
localized venous pressure or a localized weakness in the vein wall.
Studies of infant specimens showed that these dilations are normal
structures, giving rise to the anal cushion theory.

Patients and clinicians have misconceptions about haemorrhoids.

Haemorrhoidal disease is due to pathological change in anal cushions with associated symptoms.

Anatomy

The vascular hyperplasia theory was popularized in the nineteenth century; haemorrhoids were thought to be a form of metaplasia of erectile tissue. Vascular anatomy remains unchanged in
haemorrhoids.

The anal canal has a triradiate lumen lined by an irregular submucosal layer of fibrovascular tissue. This usually consists of three
lip-like structures or cushions in the left lateral, right anterior and
right posterior positions. The cushions are suspended in the anal
canal by smooth muscle fibres arising from the conjoined longitudinal muscle layer, passing through the internal sphincter, and
blending into the submucosal smooth muscle layer. Each cushion
contains a network of blood vessels, mostly venous dilations fed
by arteriovenous vessels. A framework of connective tissue and
smooth muscle surrounds this plexus of vessels.
The cushions are formed early in embryonic life. They contribute to resting anal pressure and form a compliant seal, preventing
leakage of rectal contents.

The sliding anal lining theory was proposed by Thomson

(Southampton, UK) and is the most popular. With increasing age,
the anchoring connective tissue network degenerates, leading to
distal displacement of the anal cushions. Passage of hard stools
cause shearing forces within the anal canal, exacerbating haemorrhoidal prolapse. Straining causes an increase in venous pressure,
leading to impaired venous return and stasis. Inflammation leads
to erosion of the mucosa and bleeding. Further impediment of
externally prolapsed haemorrhoids by the anal sphincter leads
to thrombosis.

Epidemiology and aetiology

Diagnosis

The prevalence of haemorrhoids is not known; hospital-based

studies are not representative, community-based studies rely on
self-reporting, and inaccuracies arise because patients and some
clinicans attribute any anorectal symptom to haemorrhoids. This
has led to prevalence rates of 4.4% amongst adults in the USA to
36.4% based at a London general practice, estimates which may
not be accurate.
Age and sex there is a general increase in prevalence (which
is equal between the sexes) with age until the seventh decade.
About 60% of hospitalized patients with haemorrhoids are men.
Women usually present during pregnancy and after childbirth.
Geographical distribution and race haemorrhoids are uncommon in rural Africa in contrast to urban Africa and developed
countries. The low prevalence was accounted for by a higher intake
of fibre; but it could also be related to poor availability and nonacceptance of medical care.
Socioeconomic status there is an increased prevalence
amongst higher socioeconomic groups.

History: data on the natural history of haemorrhoids are sparse,

but patients often undergo periods of relapse and remission;
25% of patients with symptomatic second-degree haemorrhoids
will not have another episode for a further four years. Symptoms
may vary with pregnancy, stress, diet and work patterns. Patients
experience varying degrees of symptoms, many of which are nonspecific (Figure 1).
Examination: assessment begins with careful inspection of the
perianal area for skin tags, fissures (see page 145), fistulas, polyps
and tumours, followed by digital rectal examination and anoscopy
in the left lateral position. Haemorrhoids are usually seen at 3, 7
and 11 oclock positions, although these can vary.
Classification: haemorrhoids are initially classified according to
their position relative to the dentate line. Internal haemorrhoids
originate above the dentate line; external haemorrhoids (perianal
haematomas), originate below the dentate line. The latter are not
a true part of the range of anal cushion disease, but comprise clots
within the subanodermal venous saccules.
The most commonly used grading system is based on prolapse
and reducibility into the anal canal (Figure 2), but the grades may
not reflect symptom severity.

Caron S Parsons is a Clinical Research Fellow in Colorectal Surgery at

Queens Medical Centre, Nottingham, UK.
John H Scholefield is a Professor of Surgery at University Hospital,
Queens Medical Centre, Nottingham, UK.

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OTHER ANORECTAL CONDITIONS

Complications are listed in Figure 3. Multiple banding increases

the risk of discomfort, vasovagal symptoms and urinary symptoms,
but not of major complications. Severe bleeding can occur if the
eschar from the band sloughs off, seven to ten days after the
procedure.
Patients taking antiplatelet and or anticoagulant medication
are at greater risk of secondary haemorrhage. Patients should
stop antiplatelet medication seven days before banding, and
start 14 days after banding. The patient must be fully informed
of the risk of secondary haemorrhage if the risk of discontinuing
antiplatelet medication is too high.
The risk of severe sepsis, although rare, is increased in
immunocompromised patients. Patients with prosthetic heart
valves should take their usual prophylactic antibiotics before
rubber-band ligation.
Success rates vary depending on the degree of haemorrhoids,
length of follow-up and criteria for success. The addition of fibre supplements improves outcome, increasing the long-term cure rate.
In a recent randomized trial of 255 patients comparing rubberband ligation, sclerotherapy and a combination of the two treatments
(see below), 17% of the group undergoing rubber-band ligation
alone required further treatment in the two years after the first
procedure, and 46% were symptom-free at four years; 69.1% had
minor complications (discomfort, tenesmus) and 11.1% had severe
complications (severe pain, bleeding, difficulty in urinating).
Injection sclerotherapy is reserved for first- and second-degree
haemorrhoids. An injection of 5% phenol in oil into the base of the
haemorrhoid causes submucosal fibrosis and fixation of overlying
mucosa. The correct depth of injection (characterized by a typical
swelling of the mucosa) must be ensured.
Sclerotherapy is minimally invasive, but complications can
arise (Figure 4). In the clinical trial mentioned above, 1.3% of the
sclerotherapy group complained of severe pain and 30% had minor
complications; 30% required further treatment in the 24 months
after the initial procedure, and 8% were symptom-free at four
years. There is less evidence of long-term efficacy using injection
sclerotherapy compared to rubber-band ligation.
Other treatment methods include cryotherapy and infrared
coagulation and they work on the same principle as rubber-band
ligation and sclerotherapy. They have not gained much popularity
because long-term follow-up studies have shown higher recurrence
rates in comparison to rubber-band ligation.

Symptoms

Bleeding (bright red; on wiping; in toilet bowl)

Prolapse
Soiling
Discharge
Itching
Pain (particularly if thrombosed)

Non-surgical management
Lifestyle modification: fibre supplements soften motions, relieve
constipation and reduce straining. There is conflicting evidence
from the few studies done to assess the efficacy of fibre supplementation, but it is widely recommended to patients with mild
symptoms. Advice is also given about water intake, avoiding
straining and altering the practice of defecation.
Medical treatment: many over-the-counter topical agents are available, but evidence of efficacy is scarce. Local anaesthetic agents
relieve soreness and itching. Corticosteroid creams and suppositories provide an anti-inflammatory effect, providing short-term
relief of local symptoms.
Outpatient treatment: patients may have tried lifestyle modification and medical treatment before seeking specialist treatment.
Bleeding and other symptoms that persist require treatment
targeted at underlying pathological changes. Malignancy must be
excluded before treatment for haemorrhoids in the elderly.
Rubber band ligation is the most common outpatient treatment, and can treat first- and second-degree haemorrhoids. Rubber
bands are placed above the base of the haemorrhoids i.e. above
the insensate dentate line; the procedure should be painless. The
strangulated haemorrhoid becomes necrotic and sloughs off. The
resulting fibrosis leads to fixation of the underlying tissue to the
rectal wall.
A maximum of two haemorrhoids can be ligated at one time.
If application of a single band causes discomfort, the clinician
should ensure that they are above the dentate line.

Complications of rubber-band ligation

Classification
First degree
Second degree
Third degree
Fourth degree

Bleed
Do not prolapse
Prolapse
Reduce spontaneously
Prolapse on straining
Manual reduction required
Prolapsed and irreducible

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Major
Rectal bleeding
Perianal abscess
Urinary retention
Pelvic/systemic sepsis (rare)

Minor
Haemorrhoid thrombosis
Slippage of rubber band
Mild bleeding
Mucosal ulcers

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Complications of misplaced phenol

Complications of haemorrhoidectomy

Pain
Haematuria
Haemospermia
Painful erection
Urinary tract infection and retention
Systemic sepsis (rare)

In a recent survey of British coloproctologists, only 20% did

day-case haemorrhoidectomy in 50% or more cases, despite recent
studies proving its feasibility with adequate community nursing.
Successful day-case haemorrhoidectomy is dependent on altering
patients expectations of postoperative pain using educational
tools.

Surgical management
Surgery is recommended for the treatment of third-degree (if
outpatient treatment has failed; Figure 5), and fourth-degree
haemorrhoids; about 10% of patients referred for specialist treatment require surgery.
Haemorrhoidectomy: the MilliganMorgan procedure is the most
widely used. The skin over each haemorrhoid is grasped with
artery forceps, and the haemorrhoids are prolapsed out of the anus.
Each haemorrhoid is dissected off the internal sphincter, and the
base of the vascular pedicle is transfixed and ligated. There is a
bridge of skin and mucosa between each wound at the end of the
operation. The wounds are left open to granulate.
The Ferguson technique is more popular in the USA. The
haemorrhoid is exposed in the anoscope, and haemorrhoidal tissue
is excised off the internal sphincter. Bleeding is controlled using
diathermy, and the wounds are closed with a continuous suture.
Both procedures are effective, but cause considerable postoperative pain. Many patients have pain on defecation and pain at rest
in the second and third postoperative weeks secondary to wound
infection and anal sphincter spasm (Figure 6).
Reduction of postoperative pain can be achieved by using
pre and postoperative laxatives
preoperative local anaesthetic ischiorectal fossa block
postoperative NSAIDS suppository
prophylactic metronidazole.
Restricting perioperative intravenous fluids reduces the risk of
urinary retention.

Diathermy haemorrhoidectomy is done in the same manner as

the MilliganMorgan procedure using electrocautery dissection.
The differences are that no pedicle ligation is used, and an anal
canal dressing is not required. Advocates claim that diathermy
haemorrhoidectomy is less painful in comparison to the standard
open technique, and that haemostasis is excellent.
LigasureTM haemorrhoidectomy: the device is placed across the
base of the haemorrhoid before resection, and the Ligasure TM
system delivers a controlled quantity of bipolar diathermy current, ensuring complete coagulation of blood vessels. Sphincter
damage and long-term incontinence may result because the anal
sphincters are not seen. Studies have shown no difference in
measures of incontinence between LigasureTM and other forms of
haemorrhoidectomy.
Stapled haemorrhoidopexy has become increasingly popular for
the treatment of third- and fourth-degree haemorrhoids. A modified circular stapling device (similar to those used for low rectal
anastomosis) is used to excise a ring of redundant rectal mucosa
34 cm above the dentate line and proximal to the haemorrhoids.
The aim is to resuspend the haemorrhoidal cushions back within
the anal canal and interrupt the arterial inflow traversing the
excised segment.
Complications are the same as for haemorrhoidectomy; rare
cases of severe retroperitoneal and pelvic sepsis, rectal perforation
and rectovaginal fistula have been reported. Care must be taken
with the depth of the pursestring suture to avoid injury to the
muscle of the rectal wall and the introduction of bacteria into the
perirectal tissues.
In a meta-analysis of 15 clinical trials involving 1077 patients,
qualitative analysis showed that stapled haemorrhoidopexy is
less painful compared with standard haemorrhoidectomy. It also
resulted in a shorter stay in hospital and operative time, and faster
return to normal activity. The same meta-analysis showed significantly worse recurrence rates after stapled haemorrhoidopexy. In
one of the clinical trials, at a mean of 15.9 months follow-up, recurrence rates were 11.8% after stapled haemorrhoidopexy compared
to 0% after haemorrhoidectomy for third-degree haemorrhoids,
and 50% compared to 0% for fourth-degree haemorrhoids.

5 Large third-degree haemorrhoid before haemorrhoidectomy.

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Urinary retention
Primary haemorrhage (within 24 hours)
Secondary haemorrhage (710 days postoperatively)
Anal stricture
Infection
Impaired continence (usually transient)

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