Symptoms and Diagnosis
Symptoms of hemorrhoids include local protrusion and swelling, discomfort related to protruding or swollen masses, and bleeding that may be significant enough to result in anemia. These symptoms are nonspecific, and the presence of hemorrhoids should not be presumed since more severe conditions such as inflammatory bowel disease and cancer can mimic hemorrhoidal symptoms. Patients with severe pain or incarcerated protrusions should be seen promptly.
Diagnosis is established with direct visualization by anoscopy or proctoscopy. All patients with rectal bleeding should have their colon examined to rule out proximal sources of bleeding, even in the presence of enlarged hemorrhoids. Since most sources of bright red bleeding are within the reach of a flexible sigmoidoscope, patients should undergo flexible sigmoidoscopy as well as anoscopy to rule out other causes of bleeding. Intermittent protrusion or occasional bleeding does not require urgent consultation. However, patients with acute symptoms of bleeding, pain, or incarcerated protrusions should be seen promptly.
Treatment
Initial therapy for chronic symptoms of hemorrhoidal disease should be conservative, including stool bulking and topical therapy with ointments or suppositories. Outpatient surgical treatment is appropriate if conservative treatment fails and the patient desires relief of symptoms. Operative treatment is reserved for symptomatic patients with Stage III or IV hemorrhoids. If the patient has evidence of anemia, full colonic examination is indicated and more aggressive treatment necessary.
In patients with Stage I, II, or III disease, local treatment is appropriate in the form of infrared coagulation, local injection, or rubber banding. Stage I and II diseases are effectively treated by any of these modalities, with resolution of symptoms in at least 90% of patients. Cryotherapy should be avoided because of excessive post-treatment symptoms. Stage III disease is probably best treated by hemorrhoidal banding to remove redundant tissue, but long-term resolution of symptoms is likely in only 70% of these patients. Stage IV disease requires surgical intervention, which is associated with long-term resolution of symptoms in 95% of patients. The term "laser hemorrhoidectomy" refers to excision of hemorrhoidal tissues using a laser rather than standard surgical instruments, but is a surgical procedure nonetheless.
Symptoms may also arise from residual hemorrhoidal tissue after an episode of acute thrombosis of external hemorrhoids. These external anal tags may prevent proper cleansing and can be excised during an office procedure if symptoms warrant.
Qualification for Performing Surgery for Hemorrhoids
The qualifications of a surgeon to perform any operative procedure should be based on education, training, experience, and outcomes. At a minimum, the surgical treatment of hemorrhoids should be carried out by surgeons who are certified or eligible for certification by the American Board of Surgery, the American Board of Colon and Rectal Surgery, the Royal College of Physicians and Surgeons of Canada, or their equivalent.
