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  • Writer's pictureShruti GOCHHWAL


Strangely, the term “hemorrhoids” is a term used both for normal anatomy as well as pathology of the lower rectum and anus. Anatomically, Hemorrhoids are the normal anatomical cushions composed of arterioles, venules, elastic tissue, and fat. The locations are at 3’o clock, 7’o clock, and 11’o clock in the lithotomy position(position used for gynecological examination). Pathologically, they represent dilated veins present in the lower rectum and the anus. They are also referred to as piles.


Hemorrhoids are classified by their anatomic origin and by their relative position relative to the dentate line into internal and external hemorrhoids. External hemorrhoids develop from ectoderm(skin) while internal hemorrhoids develop from endoderm(gut). Therefore external hemorrhoids are supplied by cutaneous nerves and experience pain but the deeper structures are pain-free


Symptoms of hemorrhoids include-External HemorrhoidsInternal Hemorrhoids1)    Itching around anus1)    Painless bleeding2)    Bleeding during defecation      2)  Prolapse of mass during defecation3)    Pain around anus      3)  Pain due to compressive symptoms

Causes of hemorrhoids include

  1. Constipation

  2. Obesity

  3. Pregnancy

  4. Low fiber diet

  5. Heavy-weight lifting

Proctoscopy(to view anal canal) is sufficient for diagnosing external hemorrhoids while anoscopy and flexible sigmoidoscopy are required to diagnose internal hemorrhoids and ruling out any proximal disease.



The rule to be followed in hemorrhoids is “To treat them only when the patient complains”, especially applying to the elderly people. Treatment is divided according to the type of hemorrhoids being treated.


Internal hemorrhoids do not have cutaneous innervation and therefore can be destroyed without anesthetic, and the treatment may be surgical or non-surgical. They often respond to increased fiber and liquid intake and avoidance of straining. The treatment is further divided according to the grade of hemorrhoids-

  1. Grade 1 hemorrhoids are treated with conservative medical therapy and avoidance of fatty and spicy food

  2. Grade 2 and some grade 3 hemorrhoids are treated conservatively as above

  3. Highly symptomatic grade 2 and 3 hemorrhoids are treated by surgical procedures of banding and/or sclerotherapy

  4. Grade 4 hemorrhoids generally require removal of the gangrenous and necrosed part, namely via the procedure called hemorrhoidectomy.

Stapled hemorrhoid surgery(Longo hemorrhoidectomy) is one of the best methods for treating recurrent prolapsing internal hemorrhoids not responding to conservative treatment.


External hemorrhoids symptoms are divided into problems with acute thrombosis and skin tag complaints. The former respond well to excision(not enucleation) whereas operative resection is reserved for the latter.

Operative hemorrhoidectomy has a recurrence rate of 2-5%. Non-operative techniques, such as rubber band ligation, produce a recurrence rate of 30-50% in 5-10 years.

Acutely thrombosed external hemorrhoids can be safely excised in patients who present within 48-72 hours of symptom onset. In patients presenting more than 72 hours, conservative management is preferred at first.


If managed well most of the hemorrhoids can be treated by conservative management. Retraining the patient’s toilet habit is extremely important. Decreasing straining and constipation shrink internal hemorrhoids considerably. Conservative management includes the following-

  1. Warm Bath- Bathing in a tub with warm water helps in the relaxation of the external sphincter and associated spasm easing painful perianal conditions.

  2. High fiber diet- Psyllium seed(Metamucil) and methylcellulose are the most commonly used supplements. High fiber diet includes more than 25gms of fiber per day which includes chia seeds, beans, broccoli, berries, avocados, apple, etc.

  3. Antidiarrheal agents, stool softeners- Antidiarrheal agents are required in patients with hemorrhoidal symptoms and loose stools. Stool softeners are used in constipation along with a high fiber diet.

  4. Topical agents- Topical steroids help to decrease symptoms of pruritis, inflammation and can sometimes even ease internal hemorrhoid bleeding. Topical nitroglycerine and nifedipine are also used to relieve symptoms associated with anal sphincter spasm.

Topical agents

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