Hemorrhoids
The term, "hemorrhoids" refers to groups of blood vessels in the anorectal area which are present in everyone. However, less than XX % become symptomatic from difficulties with their hemorrhoids. There are two types of hemorrhoids: internal and external. This distinction is important, because of the possible symptoms and treatment alternatives. The division is marked anatomically by the dentate line, which embryologically delineates where skin-type structures meet with rectal lining structures. Importantly, there are many nerve endings for pain distal (beyond) to this line, where the external hemorrhoids are, whereas proximal (in front) to this line, there are no pain fibers.

Both types of hemorrhoids can bleed, thrombose (clot), and prolapse. Normally, external hemorrhoids can be uncomfortable and sometimes disabling when they thrombose. Internal hemorrhoidal symptoms have been graded:

Grade 1: Bleeding
Grade 2: Prolapse, but reduce spontaneously
Grade 3: Prolapse, requiring manual reduction
Grade 4: Prolapse, unable to be reduced

Initial evaluation includes a history and physical examination. In the history, your physician will ask you questions regarding your symptoms, your diet, previous therapies and examinations. An anoscopy (3-4 inch scope inserted through your anus) may be performed to localize the problem or to determine if other problems coexist.

A thrombosed external hemorrhoid may be associated with a recent change in bowel habits. It will appear as a localized swelling around the anus, the size of a pea or grape, which may be blue or purple in color, and very tender. Pain is due to the clot itself and due to swelling associated with this process. If you are found to have an acutely thrombosed external hemorrhoid, your physician may offer you a small office procedure to remove the clot. Even without such a procedure, the clot and the swelling will dissipate, however, often in the first 24-48 hours, the pain can be so intense that you may be unable to complete your normal daily activity. A mild analgesic may be prescribed. Perianal ("around" the anus) care includes the avoidance of constipation, sitz baths (sitting in warm water several times a day and after bowel movements), and good hygiene. Despite the fact that you may have an open wound in a 'dirty' area, it is amazing that the infection and abscess formation are rare. A sequela of external hemorrhoidal disease includes residual skin tags. These are harmless, but may impair good hygiene.

Internal hemorrhoidal disease is managed dependant on symptoms. If medical management is optimal, that is, you have soft bowel movements without straining and have been compliant about observing recommendations to avoid constipation, your physician may offer several therapies to you. First and foremost, other possible explanations must be excluded, including malignancy. Therefore colonoscopy, or other visualization techniques must first be performed to exclude such a possibility. If your bleeding symptoms persist, ligation of the hemorrhoid using a rubber band is an alternative. This highly effective office-based technique applies a tight rubber ring around the hemorrhoid to strangulate a small amount of tissue. Once the ring cuts through the tissue, the ring and the tissue will fall off. This technique produces a dull ache, because, there are no true pain fibers in the area of the ligation. Complications are rare, but can be life-threatening. Your physician will discuss the complications and the signs that a complication may be evolving with you. If your internal hemorrhoidal symptoms are more complex, or are associated with external hemorrhoidal symptoms as well, surgical removal of the hemorrhoids may be warranted. A myriad of techniques may be used, including injection and coagulation of the hemorrhoids, which results in the shriveling of the hemorrhoids, removal with a surgical scalpel, an ultrasound based scalpel, suture ligation, or stapling of the lining. Your physician will discuss the advantages and disadvantages of each of these possibilities. During the post-operative period, it is important to care for yourself by avoiding constipation, and continuing good perianal care.

Less than 5% of patients seeking a colorectal surgeon with hemorrhoidal complaints need surgery. However, your physician will speak with you and outline alternatives in evaluation and treatment.