REVIEW ARTICLE

European Journal of Medical and Health Sciences

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Diagnosis and Management of Internal Hemorrhoids:

A Brief Review
P. Agus Eka Wahyudi, Stephen William Soeseno, and Febyan Febyan

ABSTRACT
Hemorrhoidal disease is a pathological condition due to the abnormal
engorgement of the arteriovenous plexus beneath the anal mucosa. Submitted: August 15, 2021
Anatomically, it can be located under the skin on the outer part of the Published: September 06, 2021
dentate line, known as external hemorrhoid; or inside the anus on the
ISSN: 2593-8339
proximal part of the dentate line, called internal hemorrhoid. Internal
hemorrhoid may further develop from a painless anal mass into protruded DOI: 10.24018/ejmed.2021.3.5.1014
and painful mass throughout the anal canal, often accompanied by
inflammation and more severe symptoms. Various management strategies P. A. E. Wahyudi
need to be considered carefully to ensure the success of therapy and improve General Surgery Department, Sanglah
the quality of life of patients with internal hemorrhoids. Conservative General Hospital Denpasar, Bali,
management is the initial stage that can be performed, including the Indonesia.
provision of high-fiber nutrition, education related to bathroom habits, and S. W. Soeseno*
the use of flavonoid regimens. Surgical therapy can be divided into Bunda Mulia Hospital Cikarang, West
Java, Indonesia.
outpatient intervention and conventional surgeries. This review will
encompass the comprehensive diagnostic approach and management of (e-mail: stephensoeseno@ gmail.com)
Febyan Febyan
internal hemorrhoids to help clinicians understand the appropriate Bhayangkara Denpasar Hospital,
management and provide better clinical benefits for the patients. Denpasar, Bali, Indonesia.

Keywords: Hemorrhoids, anorectal, anal bleeding, surgical management. *Corresponding Author

elastic and connective tissue found within the submucosal

I. INTRODUCTION space and are considered part of the normal anatomy of the
Hemorrhoidal disease (HD) is a common pathological anal canal [5]. The anal canal comprises three main cushions
anorectal condition in adulthood. It is caused by the increased in the left lateral, right anterior, and right posterior positions
pressure and abnormal dilatation of the hemorrhoidal [6]. This collection of various tissues supports the structure
vascular plexus. In the United States, HD becomes the third of the anal canal and contributes to 15%-20% of resting
most common outpatient gastrointestinal findings affecting pressure within the canal. Each cushion surrounds the
about 75% of American adults with the estimation of four arteriovenous communications between the superior and
million visits every year [1]. The prevalence is highest in the middle rectal arteries terminal branches and the superior,
Caucasian race between the ages of 45 to 65 [1]. Hemorrhoids middle, and inferior rectal veins [7]. In addition,
may develop into two types, i.e., internal and external hemorrhoidal cushions present with several crucial roles
hemorrhoids. In addition, internal hemorrhoids may develop within the anal canal. It mainly retains anal continence and
into prolapsing hemorrhoids through the anus outside the prevents stool leakage when there is increased intra-
body, which eventually becomes irritated and painful [2]. abdominal pressure (e.g., straining, coughing, and sneezing)
Hemorrhoids symptoms are often initiated by painless, by engorging with blood and causing the closure of the anal
bright red blood covering the stool and the sensation of canal [8]. In addition, hemorrhoidal cushions act to protect
impacted stool. Patients may also experience perineal itching the underlying anal sphincters during defecation. It also has a
due to the presence of mucus discharge and fecal soiling [3]. sensory function to differentiate between liquid, solid, and
Although it is a non-threatening condition, it impacts lifestyle gas and the subsequent decision to evacuate [7]. There are
and social burden. Therefore, it is important to understand several factors contribute to the development of pathologic
comprehensive management to ensure the long-term quality changes within the hemorrhoidal cushions, such as
of life of HD patients. [4]. This review aims to evaluate the constipation, prolonged straining, exercise, nutrition (low
diagnosis and management of internal hemorrhoids by the fiber intake), pregnancy, irregular bowel habits (diarrhea or
current literature reviews published. constipation), genetics problem, and the absence of valve
within the hemorrhoidal veins [9]. All these factors lead to
rising pressure within the submucosal arteriovenous plexus,
II. PATHOPHYSIOLOGY ultimately causing subsequent swelling of the cushions,
increased laxity of the supporting connective tissue, and
Theoretically, hemorrhoids are actually a highly vascular
protrusion of hemorrhoids throughout the anal canal [10].
cushion containing the arterioles, veins, smooth muscle, the

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III. DIAGNOSIS & DIFFERENTIAL DIAGNOSIS the hemorrhoids. The blood clot formation causes swelling in
Some anorectal conditions demonstrate similar symptoms the outer anal canal, causing persistent bleeding and severe
to those associated with hemorrhoids (Table I). Some pain that generally settled for 48 hours [13].
conditions must be considered carefully because the On the other hand, internal hemorrhoids are located
symptoms may be related to serious conditions, such as proximally to the dentate line and are lined by the columnar
inflammatory bowel disease or cancer. [3]. To differentiate, epithelium. The overlying columnar epithelium is viscerally
colonoscopy can be performed in patients with changes in innervated; thus, newly developing internal hemorrhoids
bowel habits, weight loss, abdominal pain, and rectal generally do not cause pain or are sensitive to touch [14].
bleeding with blood in the stool, or any family history with However, at the stage where the internal hemorrhoids have
colon cancer [3]. Physical examination for hemorrhoids completely prolapsed, one may experience severe pain. The
should be performed, such as abdominal examination, an grading of internal hemorrhoids can be divided into I to IV,
inspection of the perineum, and digital rectal examination. In which will further determine the management plan for the
some cases, digital rectal examination alone may not exclude patient (Fig. 1). Grade I is characterized by painless anal
internal hemorrhoids from external hemorrhoids; hence bleeding or asymptomatic outgrowth of anal mucosa due to
anoscopy is required. The visualization view on anoscopy in the engorgement of underlying arteriovenous plexus and
internal hemorrhoids shows dilated purplish-blue veins, and connective tissue. Grade II is characterized by painless anal
when prolapsed, the veins appear glistening dark pink bleeding with prolapsing hemorrhoid on straining but may
resembling tender masses at the anal margin. Meanwhile, spontaneously reduce. Grade III is characterized by painless
external hemorrhoids may appear less pink and, if anal bleeding with prolapsing hemorrhoids thorough the anal
thrombosed, are acutely tender with a more purplish shade canal, which can only be manually reduced. At this stage, the
[2]. The American Society of Colon and Rectal Surgeons patients are often accompanied by pruritus and fecal soiling
recommends assessing the patient with anoscopy and further due to the blockage. Lastly, grade IV is characterized by
endoscopic evaluation if there is a concern for inflammatory painless or painful anal bleeding with irreducible prolapsing
bowel disease or cancer [11]. hemorrhoids, often accompanied by chronic local
inflammatory changes [15].
TABLE I: DIFFERENTIAL DIAGNOSIS OF HEMORRHOIDS [12]
Physical
Diagnosis Historical Features Examination
Findings
Skin Tags Previous history of Tags resemble skin-
healed hemorrhoids, colored mass and are
with no bleeding. around the anus, not
on the mucosa.
Anal Fissure Bleeding with bowel Painful rectal
movement and tearing examination with
pain. fissure
Perianal Abscess Gradual onset of pain Tender mass covered
with skin as opposed
to the rectal mucosa.
Anal Cancer Pain around the anus, Ulcerating lesion of
weight loss in the anus
advanced cases
Anal Condylomata Anal mass without Cauliflower-like
bleeding; history of lesions
anal intercourse
Colorectal Cancer Weight loss, blood in Abdominal mass or
stool, abdominal pain, tenderness.
change in bowel
habit, family history
with cancer
Inflammatory Bowel Abdominal pain, Normal external
Disease constitutional rectal examination;
symptoms, diarrhea, rarely, fistula, colitis Fig. 1. Classification of internal hemorrhoids [16].
family history on anoscopy.

V. MANAGEMENT
IV. CLASSIFICATION A. Conservative Management
In general, hemorrhoids can be classified into two types, Constipation and diarrhea have been acknowledged as the
i.e., external and internal, which are classified anatomically main contributing factors in the development of hemorrhoidal
based on their location relative to the dentate line. The diseases. Therefore, recommendations suggest that adequate
external hemorrhoids are located distally to the dentate line fiber and fluid intake may improve symptoms. Integrated
and are lined by the modified squamous epithelium called patient education should be addressed regarding the
anoderm cells. These structures contain a tremendous amount consumption of daily dietary fiber 25-30 grams per day,
of innervation from the pain nerve tissue, making the external drinking 6 to 8 cups of non-caffeinated drinks, and osmotic
hemorrhoids become extremely painful on thrombosis. The laxatives as necessary. Dietary fiber should be started from a
thrombosis of external hemorrhoids occurs when there is a small amount and increase gradually so that the patients do
blood clot formation within the wall of the anal skin around

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not develop an adverse reaction, such as abdominal cramping

and bloating [17].
Moreover, the patients should be advised to avoid
unhealthy bathroom habits, including excessive straining on
the toilet and reading while in the bathroom. A prolonged
sitting position in an attempt to defecate for more than 10-15
minutes causes an increase in abdominal pressure and further
contributes to hemorrhoids engorgement. Topical
preparations including suppositories, steroid creams, and
medicated wipes are available for this condition, but no
adequate evidence supports long-term success in treating Fig. 2. Rubber band ligation of internal hemorrhoid using the suction
hemorrhoids with these topical products [18]. ligator [21].
Oral flavonoids-derivatized phlebotropic drug, such as
micronized purified flavonoid fraction (MPFF), consists of • Sclerotherapy
90% micronized diosmin and 10% hesperidin, and is This method is one of the oldest forms of non-operative
commonly used in clinical treatment. This preparation helps hemorrhoid management, first published in 1869 by Morgan
in increasing venous wall tone and lymphatic drainage, in Dublin. It is mainly indicated for improtruded (grade I and
further reducing the capillary hyperpermeability by II) internal hemorrhoids or in patients consuming regular
defending the microcirculation from inflammatory processes. anticoagulants. This procedure is administered by injecting 5
A meta-analysis of flavonoids for hemorrhoidal management, mL of 5% phenol in oil, 5% quinine and urea, or hypertonic
involving 14 randomized trials and 1514 patients, suggested (23.4%) salt solution at the base of internal hemorrhoid to
that flavonoids decreased the risk of bleeding by 67%, induce thrombosis of the blood vessels, sclerosis of
persistent pain by 65%, and itching by 35%, with a recurrence connective tissue, and shrinkage and fixation of overlying
rate of 47% [19]. mucosa [23]. An anoscope may be used to assist the
B. Outpatient Interventions procedure. Sclerotherapy is a simple procedure requiring no
If the conservative management does not provide anesthesia and takes only minutes to perform [24].
maximum results, non-surgical outpatient management can A trial study of sclerotherapy showed improvement and
be considered to treat internal hemorrhoids. These successfully cured 82% of patients, followed by 98% of
interventions are simple procedures that can be performed in patients after second sclerotherapy [25]. There are still
the surgeon’s office without anesthesia or require only local limited data on the efficacy of sclerotherapy. Nevertheless, a
anesthesia. Some examples of this type of treatment are recent trial demonstrated a 20% success rate at one year in
rubber band ligation, sclerotherapy, and infrared coagulation. treating grade III hemorrhoids [26]. The results were found
significantly better for the treatment of grade I hemorrhoids.
• Rubber Band Ligation (RBL)
This method is the most frequent anorectal outpatient A recent study by Moser et al. [27] compared the efficacy of
procedure performed in the surgery department. It is indicated polidocanol, a non-ester local anesthetic approved for use by
for grade II and III internal hemorrhoids [20]. Rubber band the United States Food and Drug Administration, with 88%
ligation does not necessarily require any local anesthetic (Fig. of patients treated successfully in 12-weeks follow up.
2). The patient lies in prone-jacknife or left lateral position, Although there are no randomized data to support the use of
and the procedure is performed through an anoscope. The sclerotherapy in anticoagulated patients, a case series
ligation procedure is assisted using the McGivney forceps described by Yano et al. [26] reported no difference in post-
ligator and the suction ligator. Small band rings are applied surgical bleeding rates from 37 patients receiving antiplatelet
therapy or anticoagulant therapy. Although sclerotherapy is a
tightly at the base of the internal hemorrhoid, specifically at
half a centimeter above the dentate line, to prevent the ring minimally invasive procedure, it may also cause
placement into somatically innervated nerve tissue. This complications, including pain which is variably reported in
70% of patients [24].
procedure aims to make hemorrhoid tissue necrotic, leaving
only a scar fixated on the rectal mucosa. Ligated • Infrared Coagulation (IRC)
hemorrhoidal tissue will undergo ischemia and become The principle of IRC therapy aims to apply infrared light
necrotic in 3-5 days, and then an ulcerated tissue bed will waves directly to the hemorrhoidal tissue to induce
form. Complete healing generally occurs within a few weeks coagulation and evaporates the water content inside the cell,
of the procedure [20]. causing shrinkage of the hemorrhoid tissue [28]. As with
The success rate of RBL ranges from 69%-97%. Post- sclerotherapy, IRC is indicated for improtruded (grade I and
surgical recurrences may occur in 6.6%-18% of patients; II) internal hemorrhoids. Firstly, a probe is applied to the base
however, a subsequent treatment course can be done to of hemorrhoid using the anoscope (Fig. 3) with a contact time
minimize its occurrence [20]. Longman et al. [22] described between 1.0 to 1.5 seconds, depending on the intensity and
different rates of complications following RBL, ranging from wavelength of the coagulator. The necrotic tissue is seen as a
3%-18.8%. Izadpanah et al. [23] summarized that 14% of white spot and eventually heals with fibrosis. The IRC is not
8,060 patients from 39 studies experienced post-banding suitable for large or prolapsing hemorrhoids conditions [28],
complications, including severe pain (5.8%), rectal [29]. The efficacy of IRC is similar to RBL, and pain
hemorrhage (1.7%), and anal fistula (0.4%). complications are minimal due to the lower volume of tissue
necrosis [30]. Although a potential alternative to RBL, this

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procedure is still limited because it is quite expensive and discovered several advantages of this procedure, including
requires a longer learning curve. lesser post-operative pain during bowel movement, earlier
post-operative bowel movement, shorter hospital stays, and
lesser pain killer requirements. Giordano et al. [36] also
supported that stapled hemorrhoidopexy is a safer technique
for managing hemorrhoids; however, it carries a significantly
higher incidence of long-term recurrences than conventional
hemorrhoidectomy. Malyadri et al. [37] reported that stapled
hemorrhoidopexy was significantly quicker to perform
compared with open hemorrhoidectomy. Hence,
hospitalization and duration of daily activity resumption were
less in the stapled hemorrhoidopexy group than open
hemorrhoidectomy. Contrary, a multicenter RCT study by
Nystrom et al. [38] reported equal rates of recurrence and
better symptomatic relief with open hemorrhoidectomy.
Therefore, the application of this procedure has been reduced
among surgeons in Europe.
Fig. 3. Infrared coagulation procedure [31].

C. Surgical Management VI. COMPLICATIONS

• Hemorrhoidectomy Various complications may occur in internal hemorrhoid
Hemorrhoidectomy is the most effective procedure in cases. They include bleeding, infection, fecal incontinence,
hemorrhoid management by completely excising the urinary retention, and anal stenosis. Fortunately, bleeding can
redundant tissue causing the bleeding and protrusion. It frequently be controlled with anal packing or suturing [17].
provides the lowest recurrence rate compared to other Infection is a rare event, but may develop into serious
procedures. This procedure can be assisted using scissors, septicemia if not acknowledged promptly and treated with
diathermy, or vascular sealing devices under perianal intravenous antibiotics [39]. Urinary retention can be
anesthesia [32]. Surgical procedure is mainly indicated if managed by inserting temporary catheterization and normally
non-surgical management fails. In clinical practice, resolved within three days after surgery [40]. Bulk-forming
excisional hemorrhoidectomy is also indicated for grade III agents, such as oral fiber supplements can be given to patient
and IV internal hemorrhoids [32]. Although simple and with post-surgical fecal incontinence [17]. Lastly, anal
effective, the drawback of this procedure is significant post- stenosis may be managed with anal dilatations [40].
operative pain. Another major post-operative complication is
acute urinary retention, affecting 2%-36% of the patients.
This procedure is often followed by the removal and VII. PROGNOSIS
pathological examination of hemorrhoidal tissue, particularly The overall prognosis of internal hemorrhoids is
if malignancy is suspected. However, hemorrhoidal satisfactory. Most early developing internal hemorrhoids can
specimens may not be pathologically examined if there is no be resolved with conservative medical treatment, with
suspicion of malignancy [33]. recurrence rates ranging from 10%-50% over five years.
• Stapled Hemorrhoidopexy Surgical management is an alternative for ineffective
This procedure is an alternative surgical procedure that is conservative and conventional approaches, with a recurrence
mainly indicated for grade II and III internal hemorrhoids. It rate of less than 5% [41].
is performed by excising the redundant tissue and
subsequently fixate hemorrhoidal tissue back into the rectal
wall [34]. The difficulty that may occur during this procedure VIII. CONCLUSION
is the application of non-absorbable purse-string sutures in a Internal hemorrhoid is a common pathological anorectal
circumferential fashion approximately four centimeters finding but a complex disease. The symptoms and signs of
proximally from the dentate line to avoid sphincter muscle internal hemorrhoids should be evaluated thoroughly, along
involvement. If the purse-string suture is overly distal to the with the determination of clinical grading. Various options
rectum, it will cause more post-operative pain, but the stapler for managing internal hemorrhoids and specific therapeutic
may create a full-thickness excision through the rectal wall if approaches should depend on each individual reasoning and
it is too proximal. This condition could lead to abscess or clinical factors. Lifestyle modifications, including high-fiber
fistula formation, requiring another surgical revision [34]. diet intake, healthy bathroom habits, and the administration
Therefore, it is crucial for the surgeon to be familiar with the of phlebotropic agents, should be initially performed.
certain stapling device prior to being executed. Other Outpatient interventions and surgical approaches should be
potentially occurring complications are sphincter muscle applied when other modalities fail. Management of therapy is
injury, bleeding, stenosis, anastomotic line dehiscence, and extremely important to prevent further complications from
recto-vaginal fistula formation. Gravie et al. [35] in a the internal hemorrhoids.
randomized controlled trial (RCT), compared open
hemorrhoidectomy to stapled hemorrhoidopexy and

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