review- article2017 TAJ0010.

1177/2040622317713957Therapeutic Advances in Chronic DiseaseSR Brown

713957
Therapeutic Advances in Chronic Disease Review

2017, Vol. 8(10) 141–147

Haemorrhoids: an update on management
Ther Adv Chronic Dis
DOI: 10.1177/

2040622317713957
Steven R. Brown
© The Author(s), 2017.

Reprints and permissions:

http://www.sagepub.co.uk/
Abstract: Haemorrhoids are common, affecting up to one quarter of all adults according to journalsPermissions.nav
some estimates. Numerous interventions exist for their management, ranging from topical
and medical therapies to outpatient treatments and surgical interventions that aim to fix or
excise. Given the polysymptomatic nature of the disease, it is difficult to effectively judge which
treatment option is best. Recently introduced novel haemorrhoid management techniques,
such as stapled haemorrhoidopexy, Ligasure™ excision and haemorrhoidal artery ligation,
aim to reduce harm whilst maintaining or improving on outcome. These new techniques
are universally more expensive, and available good quality data suggest the additional cost
does not necessarily equate to universally better outcomes compared with traditional older
interventions, such as rubber band ligation and excisional haemorrhoidectomy. Whatever the
intervention selected for treatment, it is clear that this should be tailored to the individual
based on patient choice, convenience and degree of haemorrhoids.
Keywords:  haemorrhoids, haemorrhoidectomy, rubber band ligation, injection sclerotherapy,

haemorrhoidal artery ligation

Received: 8 December 2016; revised manuscript accepted: 3 May 2017

Introduction introduced since the turn of the century. There is Correspondence to:
Steven R. Brown
Haemorrhoids represent pathological changes in the recent scientific support for some of these newer Department of Surgery,
Sheffield Teaching
anal cushions, a normal component of the anal canal options that allow an evidence-based update to Hospitals, Sheffield
involved in aiding evacuation of stool and fine- management. S5 7AU, UK.
[email protected]
tuning of anal continence. These patho-logical
changes include rupture of the supporting connective The aim of this article is to present this evidence for
tissue within the cushions, resulting in enlargement both the traditional and newer interventions and
of the vascular plexus. The patho-genesis of provide the reader with an algorithm for the modern
haemorrhoids explains the symptoms associated treatment of the disease.
with the condition: bleeding, swelling and prolapse,
seepage due to the disruption of the fine tuning of
continence and consequent irrita-tion of the perianal Conservative management
skin. More severe symptoms may include Given haemorrhoids are such a common condi-tion,
thrombosis leading to pain. first-line therapy should be prevention and minimally
interventional therapy particularly in the community
Haemorrhoids are very common, affecting as many setting. Diet and lifestyle undoubt-edly play an
as 1 in 4 of the population and resulting in a important role in haemorrhoid man-agement. Fibre
significant community and hospital practice burden. has traditionally been thought to both prevent and
Over 20,000 haemorrhoidal procedures are carried treat haemorrhoidal symptoms. Evidence for benefit
out in the UK each year.1 comes from a meta-analysis of seven clinical trials
which showed that fibre supplement relieved
Treatment options for haemorrhoids are varied; symptoms and minimized risk of bleeding by
however, the evidence base for many of these approximately 50%2 but with no effect on prolapse.
options has, until recently, been poor. Despite the Further advice to increase oral fluids, exercise
poor scientific substantiation, some of these regularly, avoid straining and constipation-inducing
treatment options have stood the clinical test of time. medications makes logical sense but there is
However, many new options have been unfortunately little evidence.

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Therapeutic Advances in Chronic Disease 8(10)

Drug therapy Table 1. Grades of haemorrhoids according to

A vast industry has evolved around preparatory the Goligher classification.
creams and suppositories for treating haemor-rhoids. Grade Description
These combinations of steroids, anaes-thetics,
antiseptics and barrier creams may be effective in I Haemorrhoids that bleed but do not
temporarily relieving the acute symp-toms of prolapse
haemorrhoidal disease. Patients often return to these II Haemorrhoids that prolapse but
agents if symptoms recur, not real-izing that spontaneously reduce
symptoms fluctuate with time and may have resolved III Haemorrhoids that prolapse but have to
with simple hygiene alone. be manually reduced

Unlike for these over-the-counter remedies, there is IV Haemorrhoids that prolapse but cannot
be reduced
some evidence for effectiveness of venotonic
therapies. Oral flavonoid medication can control
acute bleeding.3 They increase vascular tone, reduce
venous capacity, decrease capillary perme-ability, to warrant admission.7 Other complications include
facilitate lymphatic drainage and have anti- bleeding and vaso-vagal symptoms. Rarely the
inflammatory effects. A large meta-analysis showed bleeding is severe enough to require admission and
that venotonics have significant beneficial effects on blood transfusion. There have been reports of severe
bleeding, pruritus, discharge and over-all symptom pelvic sepsis with a few instances leading to death.6
improvement.4

The procedure meets several criteria for the opti-

Outpatient interventions mum outpatient therapy. It is certainly cheap, quick
and easy to carry out. It also seems to be very safe in
Rubber band ligation the majority of people. Efficacy may not be as high
Various outpatient treatments for symptomatic as some operative interventions but improves with
haemorrhoids exist. In the UK and many other repeat procedures.8 The common symptom of short-
countries, rubber band ligation (RBL) is the most lived pain may be reduced with local anaesthetic
commonly performed of these therapies. 5 RBL uses a injection.9
device that allows a rubber band to be applied to
each haemorrhoid via a proctoscope. This band
constricts the blood supply causing the haemor-rhoid Injection sclerotherapy
to become ischaemic before being sloughed Various sclerosant solutions have been used for
approximately 1–2 weeks later. The resultant fibro- injecting piles. The comparative efficacy of these
sis reduces any element of haemorrhoidal prolapse solutions is unclear. Less potent solutions such as 5%
that may have been present. Although easy to per- phenol in almond oil are more commonly used and
form, and with a short learning curve, care has to be probably have a lower risk of mucosal necrosis.
taken to place the bands correctly to reduce the Injection treatment is simple, safe and rapid, but
potential for severe pain. probably not as effective as RBL.10 This treatment
modality should probably be reserved for patients
The literature concerning efficacy and safety of RBL where bleeding is the main symptom and
is substantial.6 Reported recurrence rates are broad conservative therapy has not improved the symptoms
(from 11% to over 50%). This varia-bility reflects (and other causes having been excluded). Other
the poor definition of recurrence, the grade of indications possibly include patients with a high risk
haemorrhoids (see Table 1), the number of treatment of secondary haemorrhage (patients on
episodes and the length of follow up. In most studies, anticoagulants and patients with advanced cirrhosis)
recurrence is >30% and is more likely with and those who are immunocompromized.11,12
increasing prolapse. Recurrences can be treated by
re-banding or by surgical intervention.
Complications include bleeding (either immedi-ate
or secondary), pain (which can be localized or rarely
Immediate pain is common, although it often only liver pain due to porto-systemic injection), or
lasts a few hours after the procedure. In 1% of prostatic symptoms if the injection is placed too
patients undergoing RBL, pain is severe enough deeply. Injection of the prostate can result in

142 journals.sagepub.com/home/taj
 SR Brown

urinary retention (often resolving spontaneously), particularly as efficacy is not clear. With this caveat,
epididymitis, prostatitis (presenting as pain in the combination of RBL with injection sclerotherapy
ejaculation and haemospermia) and even pros-tatic does make practical sense. Not only is the double
abscess.10 therapy a ‘belt and braces’ approach but also the
bolus of sclerosant below the band ligation may act
to secure the band, reducing fail-ure due to
Infrared coagulation premature slippage.
Infrared coagulation consists of a direct applica-tion
of infrared waves to the haemorrhoidal pedi-cle
resulting in necrosis and sloughing of the pile. Surgical therapy
Several applications are required per haemor-rhoid
but each takes a few seconds. Complications and Haemorrhoidectomy
efficacy are similar to RBL with some sug-gesting Surgical excision of haemorrhoids is perhaps one of
less pain presumably related to the lower volume of the oldest operations ever performed. Although there
tissue necrosis.13–16 Although a poten-tial alternative are numerous variations of the technique two
to RBL, the equipment is expen-sive and there is a essential operations exist; open excision (Milligan–
longer learning curve. Morgan) and closed haemorrhoidec-tomy
(Ferguson). For the open technique, the skin-covered
external element of the haemorrhoid is excised
Other therapies together with the mucosal element with ligation to
the haemorrhoidal pedicle, taking care to preserve
Bipolar, direct current and the intervening mucosal bridges. Ferguson
radiofrequency ablation therapy haemorrhoidectomy also removes the vascular
Application of low wattage bipolar diathermy results haemorrhoidal tissue but preserves the anoderm,
in tissue coagulation. The process takes up to 30 s theoretically limiting post-operative discharge and
and multiple applications to the same site are often accelerating the healing process.
required.17 Complications, including pain, bleeding
and fissuring, occur in around 10% of patients. More recent ‘advances’ in the open technique have
involved different technologies to excise the
Direct current therapy has gained recent favour in haemorrhoid including diathermy, lasers and
the form of Ultroid therapy, although the reasons for ultrasonic dissectors. A variation of the Ferguson
its popularity, other than aggressive market-ing, are technique involves the Ligasure™ (Medtronic Minn,
unclear. The procedure involves applica-tion of a USA) coagulator which is postulated to seal the
probe onto the haemorrhoidal cushion and tissue with minimal thermal spread result-ing in less
application of a low direct current for around 10 min post-operative pain.
per haemorrhoid. Results are at best equivalent to
injection sclerotherapy18 and RBL, but with the All of these techniques have potential complica-
procedure taking significantly longer. tions, including pain, bleeding, urinary retention,
infection, iatrogenic fissuring, stenosis and incon-
Radiofrequency ablation cuts and coagulates tinence. Manouvres to reduce all of these compli-
haemorrhoidal tissue using less power (and hence cations have been described. Metronidazole
less temperature) than other electrical equipment. A theoretically reduces pain by reducing the poten-tial
comparison with RBL suggested similar effi-cacy to for micro-abscess formation. A total of five trials
RBL with less pain.19 Again equipment is expensive including more than 350 patients have shown that
and the procedure has not gained uni-versal either oral or topical metronidazole reduces post-
acceptance. operative pain after open haemor-rhoidectomy. 22–26
Commencing laxatives prior to operation seems
appropriate to prevent post-operative constipation
Combination therapy but has been shown to be of direct benefit in one
Numerous combinations of therapies have been small low quality trial.27
described and include RBL with injection sclero-
therapy20 or infrared coagulation.21 Again, the
studies are of poor quality. Indeed, the description of Procedure for prolapsed haemorrhoids
some therapies involves almost daily outpatient The procedure for prolapsed haemorrhoids, or
visits over a few weeks. Such an intense therapy stapled haemorrhoidopexy, utilizes a circular sta-
negates the advantage of an outpatient procedure, pling device to excise a doughnut of mucosa

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Therapeutic Advances in Chronic Disease 8(10)

immediately above the haemorrhoidal complex. In haemorrhoidal disease and duration of follow up will
doing so the procedure not only disrupts the blood also influence the estimate of efficacy. The literature
supply to the plexus, reducing engorge-ment, but is generally poor in defining all of these parameters.
also pulls any redundant mucosa into the anal canal These drawbacks combined with the multiple
reducing any prolapse. As there is no incision in the interventions and variations of interven-tions that are
sensitive anal mucosa, theoreti-cally pain is reduced reported make any pooled meta-analysis extremely
and recovery enhanced; indeed, good evidence difficult. Nevertheless, there have been attempts to
supports this idea.28–30 define which procedure is best with a general
consensus that treatment probably needs to be
Some complications such as bleeding, discomfort tailored to the individual depending on symptoms,
and urinary retention are similar to other haemor- grade of haemorrhoids and patient expectation.34,35
rhoidal operations. However, there are some more
unique potential complications that may be serious.
These include rectovaginal fistulae, rectal perforation A total of two meta-analyses have been published
and retroperitoneal sepsis. A unique syndrome of regarding outpatient treatment of grade I and II
pain, urgency and tenesmus has been described and haemorrhoids, both in the 1990s.36,37 Infrared
may respond to topical nifedipine.31–32 coagulation is stated in one as the outpatient
treatment of choice, whereas the other, more
extensive article concludes that RBL is the most
efficacious, although this review does note the
Haemorrhoidal artery ligation association with more pain than the other options.
A recent intervention that has gained in popular-ity is
haemorrhoidal artery ligation (HAL). This utilizes a A more recent network meta-analysis has exam-ined
modified proctoscope, which incorpo-rates a Doppler the interventions for grade III and IV haem-orrhoids.
probe. The device allows accurate detection of the This analysis compared 12 variations of potential
haemorrhoidal arteries feeding the anal cushions. interventions and included an analysis of 98 papers.38
Targeted ligation of the vessels reduces
haemorrhoidal engorgement whilst at the same time
allowing fixation of the cushion reduc-ing the In terms of harm they found the following: open,
potential for prolapse. The suture may be modified to closed and radiofrequency haemorrhoidectomies
incorporate a ‘pexy’ suture and enhance reduction of resulted in an increased likelihood of complica-tions
any existing prolapse. The procedure is simple and compared with HAL, Ligasure™ and ultra-sonic
easy to learn. As there is no surgical wound and the techniques. HAL resulted in less bleeding potential
sutures are applied above the dentate line, pain is than open and stapled haemorrhoi-dopexy and
theoretically reduced and recovery enhanced. resulted in fewer urgent reoperations than open,
Significant liter-ature has suggested this is the case. closed, stapled and Ligasure™ proce-dures. Open
Pain tends to be moderate and recedes in the first few and closed haemorrhoidectomies were more painful
days after surgery such that there is minimal to no in the first 24 h than stapled, HAL, Ligasure™ and
pain by 1–3 weeks.6 Complications include (usually ultrasonic techniques.
mild) bleeding, urinary retention, thrombosis and fis-
sure formation.33 In terms of recovery, normal activities were resumed
earlier in the stapled, Ligasure™ and ultrasonic
groups than the open and closed
haemorrhoidectomies.
Which is surgery most effective and
causes the least harm? In terms of recurrence this was more common after
The question of which surgical therapy is most stapled haemorrhoidectomy and HAL than after
effective is the crux to any summary of manage- open, closed and Ligasure™ haemorrhoidectomy.
ment. The question is not easy to answer.
Haemorrhoidal disease is a multisymptomatic None of these meta-analyses have included the most
condition and as such it is difficult to define cure or recent series of randomized controlled trials (RCTs)
recurrence. For instance, one intervention may stop on haemorrhoidal disease. The first was a
bleeding in one patient, but leave an element of comparison of RBL with HAL for grade II or early
prolapse. If the patient is not bothered by the grade III haemorrhoids.39 In this trial, recur-rence
prolapse, is he or she ‘cured’? Severity of was very carefully defined using a simple

144 journals.sagepub.com/home/taj
 SR Brown

patient reported outcome backed up by hospital conventional haemorrhoidectomy with the method of
records. HAL was found to be more effective than haemorrhoidectomy being unclear other than scissor
RBL at 1 year. However, HAL was as effec-tive as ‘a or diathermy excision being the most cost effective.
course’ of RBL (1 or 2 sessions of band-ing). All If open haemorrhoidectomy is carried out there is
other parameters were the same except cost. HAL reasonable evidence for the use of metronidazole
was significantly more expensive. postoperatively. Stapled haemorrhoidopexy should
not be completely dis-missed as an option. It should
A second high-quality RCT compared stapled probably be used for those cases of circumferential
haemorrhoidopexy with conventional haemor- prolapse where an excisional haemorrhoidectomy
rhoidectomy for grade II–IV haemorrhoids.40 In tech-nique that preserves adequate mucosal bridges
agreement with many trials, stapled haemorrhoi- is difficult.
dopexy was found to be less painful than conven-
tional haemorrhoidectomy in the short term and
complication rates were similar. However, quality of Funding
life was significantly better in the conventional This research received no specific grant from any
group over the 2-year follow up, and the cost of the funding agency in the public, commercial, or not-for-
stapled haemorrhoidectomy procedure was profit sectors.
significantly greater.
Conflict of interest statement
A third trial compared HAL with stapled haemor- The author declares that there is no conflict of
rhoidopexy41 and found that although the HAL interest.
resulted in less pain, the procedure took longer, was
more expensive and probably resulted in a higher
recurrence rate.
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