Hemorrhoids are swollen blood vessels in and around the anus and lower rectum that stretch under pressure, similar to varicose veins in the legs. Swollen hemorrhoids may result from heredity, aging, and/or increased pressure from pregnancy, straining to move the bowel, or chronic constipation or diarrhea.
Hemorrhoids are either inside the anus (internal) or under the skin around the anus (external). The diagnosis of internal and/or external hemorrhoids is made by inspection, digital examination, and/or direct vision through the anoscope and proctoscope. Internal hemorrhoids are a plexus of veins that represent a vascular cushion covered by loose areolar submucosal tissue of the lower rectum. They occur in three primary positions: right anterior, right posterior, and left lateral. Smaller hemorrhoids may occur between the primary locations.
Treatment is necessary only when hemorrhoids become enlarged and symptomatic. First-degree internal hemorrhoids cause painless bright red rectal bleeding at the time of defecation. At this early stage there is no prolapse, and anoscopic examination reveals enlarged hemorrhoids projecting into the lumen. Second-degree internal hemorrhoids protrude through the anal canal on gentle straining, but spontaneously reduce. Third-degree internal hemorrhoids protrude with straining and must be reduced manually after defecation. Fixed protrusion defines fourth-degree internal hemorrhoids.
Infrared coagulation, also called photocoagulation, is used to treat symptomatic first- and second-degree internal hemorrhoids. Pulses of infrared radiation are applied to the hemorrhoidal base through a hand-held applicator. These pulses produce a discreet area of necrosis, which heals to form a scar. This reduces or eliminates blood flow through the hemorrhoid, thereby shrinking it, and the mucosa becomes fixed to the underlying tissue. The procedure is easily performed in a physician’s office, has few complications, and results in less discomfort for the patient. This is not a staged procedure, and the occasional need for a follow-up procedure during the 90-day postoperative period is considered to be a part of the routine follow-up care. With appropriate treatment, all patients with symptomatic hemorrhoids should become asymptomatic. A conservative approach should be used initially in nearly all cases.
Electrocoagulation, monopolar coagulation, bipolar coagulation, microcurrent, direct-current, and galvanic current are electrocautery techniques that destroy hemorrhoids by thermal methods. Coagulation causes the hemorrhoid tissue to harden and degenerate. Cryotherapy is no longer recommended because of the long healing time and rate of complications.
Doppler-guided hemorrhoidal artery ligation (DGHAL) is a new approach to surgical treatment of hemorrhoids. DGHAL uses a proctoscope and Doppler ultrasound probe to identify and suture-ligate the terminal branches of the hemorrhoidal arteries. It is minimally invasive, and is considered to be less painful than other surgical hemorrhoid treatments.