What are the effects of treatments for hemorrhoidal disease?

BENEFICIAL

Rubber Band Ligation

One randomized controlled trial (RCT) showed that fewer persons with second-degree hemorrhoids had persistent symptoms 48 months after rubber band ligation compared with no treatment. In three RCTs, rubber band ligation was shown to be similarly effective at controlling symptoms as infrared coagulation in persons with mainly first- and second-degree hemorrhoids. A fourth RCT showed that rubber band ligation was more effective at controlling bleeding. The four RCTs had conflicting results regarding postoperative pain.

Three RCTs showed that rubber band ligation was better than injection sclerotherapy in a variety of outcomes (pain, repeat treatment, prolapse, bleeding) in persons with mainly second-degree hemorrhoids; however, rubber band ligation was associated with more immediate adverse effects. One RCT showed increased bleeding in the short term with rubber band ligation compared with stapled hemorrhoidectomy in persons with mainly third-degree hemorrhoids, although there was no significant difference after two months. However, the RCT showed fewer adverse effects with rubber band ligation. Two RCTs showed no significant difference between rubber band ligation and open excisional hemorrhoidectomy in bleeding. One of the RCTs showed that rubber band ligation was less effective for prolapse in persons with third-degree hemorrhoids but showed no significant difference in patients with second-degree hemorrhoids.

LIKELY TO BE BENEFICIAL

Closed Hemorrhoidectomy

One RCT showed no significant difference between closed hemorrhoidectomy and hemorrhoidal artery ligation in symptom relief in persons with first- to fourth-degree hemorrhoids; however, length of hospital stay and postoperative complications were increased with closed hemorrhoidectomy. One systematic review and subsequent RCTs comparing conventional surgery (open excisional and closed hemorrhoidectomy) with stapled hemorrhoidectomy had mixed results for symptom reduction and length of hospital stay. However, the systematic review and RCTs showed that postoperative pain and complications were greater with conventional surgery. RCTs showed no significant difference in length of hospital stay and symptom relief between closed and open excisional hemorrhoidectomy in persons with mainly third- and fourth-degree hemorrhoids. The RCTs also had mixed results regarding postoperative pain.

Open Excisional (Milligan-Morgan/Diathermy) Hemorrhoidectomy

Two RCTs showed no significant difference between open excisional hemorrhoidectomy and rubber band ligation in bleeding. One of the RCTs showed that open excisional hemorrhoidectomy was more effective for prolapse in third-degree hemorrhoids but showed no significant difference in second-degree hemorrhoids. Two RCTs showed longer hospital stays and worse postoperative pain after open excisional hemorrhoidectomy compared with radiofrequency ablation in persons with third-degree hemorrhoids. Another RCT also showed longer hospital stays and worse postoperative pain with open excisional hemorrhoidectomy compared with semiopen hemorrhoidectomy (degree of hemorrhoids unknown). RCTs showed no significant difference in length of hospital stay and symptom relief between open excisional and closed hemorrhoidectomy in persons with mainly third- and fourth-degree hemorrhoids. RCTs also had mixed results regarding postoperative pain.

RCTs that compared open excisional hemorrhoidectomy by conventional procedures with other procedures (LigaSure, Harmonic scalpel, bipolar scissors) had conflicting results regarding length of hospital stay. They showed no significant difference in postoperative pain. One systematic review and subsequent RCTs comparing conventional surgery with stapled hemorrhoidectomy had mixed results regarding symptom reduction and length of hospital stay. However, the systematic review and RCTs showed greater postoperative pain and complications with conventional surgery.

Infrared Coagulation/Photocoagulation

One RCT showed no significant difference between infrared coagulation and injection sclerotherapy in symptom reduction or adverse effects in persons with first- and second-degree hemorrhoids. Another RCT showed that infrared coagulation was more effective at reducing symptoms than injection sclerotherapy and caused less immediate postoperative pain. In three RCTs, infrared coagulation was shown to be similarly effective at controlling symptoms as rubber band ligation in persons with mainly first- and second-degree hemorrhoids. However, a fourth RCT showed that infrared coagulation was less effective at controlling bleeding. The four RCTs had conflicting results regarding postoperative pain.

TRADE-OFF BETWEEN BENEFITS AND HARMS

Stapled Hemorrhoidectomy

One RCT showed less bleeding in the short term with stapled hemorrhoidectomy compared with rubber band ligation in persons with mainly third-degree hemorrhoids, although there was no significant difference after two months. However, the RCT showed more adverse effects with stapled hemorrhoidectomy. One systematic review and subsequent RCTs comparing stapled hemorrhoidectomy and conventional surgery had mixed results regarding symptom reduction and length of hospital stay. However, postoperative pain and complications were less with stapled hemorrhoidectomy.

UNKNOWN EFFECTIVENESS

Injection Sclerotherapy

One RCT showed no significant difference between injection sclerotherapy and education and advice regarding bleeding in persons with first- and second-degree hemorrhoids; however, fewer persons were given bulk-forming evacuant with injection sclerotherapy. One RCT showed no significant difference between injection sclerotherapy and infrared coagulation in symptom reduction or adverse events in persons with first- and second-degree hemorrhoids. Another RCT showed that injection sclerotherapy was less effective at reducing symptoms than infrared coagulation and caused more immediate postoperative pain. Three RCTs showed that injection sclerotherapy was worse than rubber band ligation in a variety of outcomes (pain, repeat treatment, prolapse, and bleeding) in persons with mainly second-degree hemorrhoids; however, injection sclerotherapy was associated with less immediate adverse effects.

Hemorrhoidal Artery Ligation

One RCT showed no significant difference between hemorrhoidal artery ligation and closed hemorrhoidectomy in relief of symptoms in persons with first- to fourth-degree hemorrhoids; however, length of hospital stay and postoperative complications were improved with hemorrhoidal artery ligation.

Definition

Hemorrhoids are cushions of submucosal vascular tissue in the anal canal that start just distal to the dentate line. These vascular cushions are normal anatomic structures of the anal canal, and their existence does not necessarily indicate actual hemorrhoidal disease. Hemorrhoidal disease occurs when there are symptoms such as bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus. Rectal bleeding is the most common manifestation of hemorrhoidal disease. The blood tends to be bright red and can appear on toilet tissue or drip into the toilet. Hemorrhoids can occur internally or externally or can have internal and external components. If prolapse occurs, a perianal mass may be evident with defecation.

Hemorrhoids are traditionally graded into four degrees. First-degree hemorrhoids bleed with defecation but do not prolapse. Those hemorrhoids associated with mild symptoms usually are secondary to leakage of blood from mildly inflamed, thin-walled veins or arterioles. Conservative management with dietary manipulation (addition of fiber) and attention to anal hygiene often is adequate. Recurrent rectal bleeding may require ablation of the vessels with nonsurgical techniques (e.g., injection sclerotherapy, infrared coagulation, rubber band ligation). Infrared coagulation is used infrequently in clinical practice in the United Kingdom, whereas rubber band ligation and injection sclerotherapy are common.

Second-degree hemorrhoids prolapse with defecation and reduce spontaneously. These hemorrhoids can be treated with rubber band ligation or other nonsurgical ablative techniques. Third-degree hemorrhoids prolapse and require manual reduction. With these hemorrhoids, there is significant destruction of the suspensory ligaments. Relocation and fixation of the mucosa to the underlying muscular wall generally is necessary. Prolapse initially can be treated with rubber band ligation, although hemorrhoidectomy may be required, especially if prolapse occurs in more than one position. Fourth-degree hemorrhoids prolapse and cannot be reduced. If treatment is necessary, these hemorrhoids require hemorrhoidectomy.

Hemorrhoids are thought to be associated with chronic constipation, straining to defecate, pregnancy, and low dietary fiber intake. Frequency, duration, and severity of hemorrhoidal symptoms (e.g., bleeding, prolapse, or both) determine the type of treatment. Often, absent or episodic symptoms do not require treatment, and the presence of symptoms does not mandate invasive treatment. Some persons decline treatment if they are appropriately reassured that there is not a more serious cause for their symptoms.

Incidence and Prevalence

Hemorrhoids are thought to be common in the general population, although no reliable data regarding incidence were found. Data from the National Center for Health Statistics found that 10 million persons in the United States complained of hemorrhoids, leading to a prevalence rate of 4.4 percent.¹ However, a true figure for prevalence of hemorrhoids is unknown, because many persons with the condition never consult a medical professional.

Etiology

The cause of hemorrhoids remains unknown, but it is thought that a downward slide of the anal vascular cushions is the most likely explanation.² Other possible causes include straining to defecate, erect posture, and obstruction of venous return from raised intra-abdominal pressure, as in pregnancy. Some persons may have a hereditary predisposition, possibly related to a congenital weakness of the venous wall.

Diagnosis

Accurate diagnosis requires a detailed history, thorough examination, and proctoscopic inspection of the anal canal and distal rectum. In patients with atypical symptoms, it is important to exclude other conditions such as colorectal cancer or inflammatory bowel disease.

Prognosis

The prognosis is generally excellent for persons with hemorrhoids, because many symptomatic episodes of hemorrhoids resolve with conservative measures. If further intervention is required, the prognosis remains very good, although recurrent symptoms may occur. Early in the clinical course of hemorrhoidal disease, prolapse reduces spontaneously. Later, the prolapse may require manual reduction and may cause mucus discharge, which can cause pruritus ani. Pain usually is not a symptom of internal hemorrhoids unless prolapse occurs. Pain may be associated with thrombosed external hemorrhoids. Death from hemorrhoidal bleeding is rare.