Did you know that around one in every twenty Americans suffers from hemorrhoids and that about half of the adults older than the age of 50 have hemorrhoids? Yes, hemorrhoids undoubtedly have a significant impact on the health of many people in the USA and worldwide.

Hemorrhoids are enlarged anal cushions that move further away from the urethra. They are caused by various reasons, including constipation and excessive straining.

Throughout the history of medicine, the ways of treating hemorrhoids have not changed. Hippocrates used various surgical methods, including ligature operation, excision, and cautery. These techniques have been carried out through the decades with just minor modifications, but they serve as the foundation for all hemorrhoid surgeries currently in use.

In addition, the fact that hemorrhoids are frequently addressed in historical works demonstrates the lasting impact that this illness has had on people. Below you will find an overview of hemorrhoidal disease followed by the most recent non-invasive and surgical treatment options.

Hemorrhoids Classification and Grading System

A hemorrhoid classification system is beneficial for selecting appropriate treatments. Hemorrhoids are often characterized according to where and how far they have prolapsed.

There are three types of hemorrhoids, including Internal Hemorrhoids (positioned deep within the rectum and cannot be seen or felt without specialized inspections and treatments), External Hemorrhoids (found outside the rectum, typically near the anus), and Mixed Hemorrhoids (appear both above and below the dentate line).

Grade I (First-Degree Hemorrhoids) bleed but do not prolapse through the anal cushions.
Grade II (Second-Degree Hemorrhoids) prolapse through the anal cushions due to straining, followed by a reduction in size.
Grade III (Third-Degree Hemorrhoids) prolapse through the anal cushions due to exertion and require manual replacement
Grade IV (Fourth-Degree Hemorrhoids) prolapse is visible at all times and cannot be reduced.

Treatments	Grade 1	Grade 2	Grade 3	Grade 4
Sclerotherapy	X	X	N/A	N/A
Infrared Coagulation	X	X	N/A	N/A
Radiofrequency Ablation	X	X	N/A	N/A
Rubber Band Ligation	X	X	N/A	N/A
Plication	N/A	X	X	N/A
Hemorrhoidectomy	N/A	X	X	N/A
Stapled Hemorrhoidopexy	N/A	N/A	X	X

Sclerotherapy

If you have grade 1 or 2 hemorrhoids, sclerotherapy may be an option. To examine the membranes that line the anus, a doctor uses Proctoscope (a tiny tube with a light attached).

An injection of a drug-containing liquid into the area around the enlarged hemorrhoids is then performed using a proctoscope and medications such as policosanol, quinine, or zinc chloride. Injections are given on a biweekly basis in most cases.

This technique reduces their size by destroying blood arteries and limiting blood flow to the hemorrhoids. If all of the enlarged hemorrhoids are treated, it may be necessary for the procedure to be repeated multiple times.

Swelling or infections may also occur in rare circumstances due to this surgery. After two to three years, hemorrhoids may reappear in some people.

Infrared Coagulation

The infrared coagulator releases infrared radiation, which coagulates tissue and evaporates water within the cell, causing the hemorrhoid mass to contract and eventually shrink. Through the anoscope, a probe is applied to the base of the hemorrhoid. The suggested contact time ranges between 1.0 and 1.5 seconds depending on the intensity and wavelength of the coagulator.

The necrotic tissue appears as a white patch on the skin and subsequently heals with fibrosis after the operation. In comparison to sclerotherapy, infrared coagulation (IRC) is less technique-dependent and does not have the potential problems associated with a misdirected sclerosing injection. However, IRC is may not be appropriate for prolapsing hemorrhoids.

Rubber Band Ligation

Hemorrhoids of the first and second degrees are treated with rubber band ligation (RBL), a simple, rapid, and effective procedure. After the hemorrhoidal tissue is tied together with a rubber band, it suffers from ischemic necrosis, which results in the connective tissue becoming permanently attached to the rectal wall. Due to the existence of somatic nerve afferents, the placement of a rubber band too close to the dentate line may result in significant pain.

RBL can be performed safely in a single session using several commercially available instruments, such as the hemorrhoid ligator rectoscope and endoscopic ligator, which use suction to draw the redundant tissue into the applicator, allowing the procedure to be completed by a single person without the use of anesthesia.

Symptoms such as soreness or rectal discomfort can be alleviated with mild analgesics, warm sitz baths, and stool softeners. Besides minor bleeding from mucosal ulceration, further problems include urinary retention, thrombosed external hemorrhoids, and, in rare cases, pelvic infection.

Radiofrequency Ablation

RFA is a relatively new technique. In this procedure, a ball electrode attached to a radiofrequency generator is put on the hemorrhoidal tissue, causing the tissue to evaporate. The vascular components of hemorrhoids are reduced, while the hemorrhoidal mass is bonded to the underlying tissue after fibrosis.

RFA can be performed as an outpatient procedure using an anoscope, similar to sclerotherapy. Wound infection, perianal thrombosis, and acute urine retention are among the side effects of this procedure. Even though RFA is a painless technique, it is associated with a higher incidence of recurrent bleeding and prolapse.

Plication

It is possible to restore anal cushions to their normal position with plication without surgery. Oversewing the hemorrhoidal mass and making a knot at the highest vascular pedicle are the steps involved in this operation. While this operation is relatively safe, there are still several potential problems, including bleeding and pelvic pain.

Hemorrhoidectomy

Hemorrhoidectomy has shown to be the most effective treatment, with the lowest recurrence rate. It is performed using diathermy, while in some cases, it is conducted with a vascular-sealing device such as the Harmonic scalpel or Ligasure. Hemorrhoidectomy under perianal anesthetic infiltration can be safely performed with minor complications as an ambulatory procedure.

Stapled Hemorrhoidopexy

It is possible to perform staple-assisted Hemorrhoidopexy on hemorrhoids that have been removed from the anal canal by excising the superfluous mucosa around the hemorrhoids and resuspending the hemorrhoids in their original position within the anal canal. While the surgery is being performed, the blood supply to the hemorrhoidal tissue is cut off.

A recent meta-analysis comparing the surgical outcomes of SH and hemorrhoidectomy revealed that the use of SH was associated with an earlier return of bowel function, less pain, shorter hospital stay, improved wound healing, and a higher level of patient satisfaction. The meta-analysis was published in the Journal of the American College of Surgeons.

Due to the expensive cost of the stapling device and the possibility of side effects such as rectal stricture rectovaginal fistula, SH is mainly reserved for patients with prolapsing hemorrhoids or fewer than three lesions of advanced internal hemorrhoids.

The Final Cut

Hemorrhoids are treated in various ways, depending on the symptoms. Even though surgery is an effective treatment for hemorrhoids, it should only be performed in the case of advanced disease.

Meanwhile, non-operative treatments, particularly those based on a topical or pharmaceutical approach, are not always beneficial in all cases. Therefore, it is essential to consult a qualified and experienced proctologist or colorectal surgeon.