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Hemorrhoids are often accompanied by anal itching, pain, bleeding and oozing.

Hemorrhoids are arteriovenous vascular cushions that are arranged in a circular pattern in the submucosa of the rectum and seal the anal sphincter. In the case of hemorrhoidal disease, these cushions are dilated/enlarged. They sometimes prolapse into the anal canal or outwards. Typical hemorrhoidal symptoms are perianal swelling, excruciating itching, pain and burning in the anus area, transanal bleeding, anus wetting and stool smearing. The classification depends on the stage and ranges from grade I to IV, the transitions are fluid. Treatment depends on the stage and severity of the symptoms. For grade I-II hemorrhoids, stool-regulating measures, local therapy and minimally invasive procedures such as sclerotherapy or rubber band ligation are used. In the case of advanced or high-grade haemorrhoids (grade III-IV), surgical treatment is often the only option.

Hemorrhoids: Hemorrhoids are vascular convolutions that are physiologically present in every person and in every age group. The corpus cavernosum recti (CCR) is a broad-based, spongy vascular cushion that lies in a ring shape in the submucosa of the distal rectum and ends immediately above the dentate line in the anorectal transition zone. They ensure fine sealing of the anus and fine continence of the anal canal.

Hemorrhoidal disease: Hemorrhoidal disease or symptomatic hemorrhoids are enlarged or dilated hemorrhoids that are accompanied by symptoms.

Hemorrhoidal complaints: Hemorrhoidal symptoms refer to the symptoms associated with hemorrhoidal disease.

Epidemiology

Haemorrhoidal disease is one of the most common diseases in industrialized nations. The incidence of patients visiting a doctor's practice for this reason is estimated at around 4 percent. The peak incidence for both sexes is between the ages of 45 and 65. In some studies, women and men are affected equally often, while other studies describe an increased prevalence in male patients.

Despite the frequency of hemorrhoidal disease, there is little meaningful epidemiological data. One reason for this is that many people avoid seeing a doctor out of shame and resort to self-treatment. The diagnosis is also problematic. Patients and non-proctologically trained medical staff sometimes diagnose haemorrhoids although the cause of the symptoms is another anorectal disease.

Causes

The exact etiology of hemorrhoidal disease is not known for certain. Depending on the study, there are different and sometimes contradictory results. A multifactorial process seems likely. In general, the prolapse theory (see pathogenesis) has established itself as the pathogenetic hypothesis for the development of hemorrhoidal disease.

AV shunts or hypervascularization: AV shunts or hypervascularization may be partly responsible for the development of haemorrhoidal disease. Background to the assumption: Sphincter-like structures between the vascular plexus in the subepithelial space of the anal transition zone restrict the arterial blood inflow and enable adequate venous return flow. In hemorrhoidal disease, these are significantly reduced - resulting in increased blood filling of the arteriovenous plexus. Anal sphincter pressure: Whether changes in the anal sphincter or the intra-anal pressure conditions lead to enlarged haemorrhoids has not been proven. The increased resting pressure measured in most studies in patients with hemorrhoidal disease could play an etiopathogenetic role, but could also occur as a consequence.

Pathogenesis

The most common pathogenetic hypothesis of hemorrhoidal disease is the prolapse theory or "sliding anal lining" theory according to William Hamish Fearon Thomson. This describes a progressive distal displacement of the corpus cavernosum recti.

"Sliding anal lining" theory: According to Thomson's theory, the hemorrhoidal plexus is displaced distally and enlarged due to increased intra-abdominal pressure, for example during pregnancy or when pushing. The increase in pressure leads to destruction or displacement of the tissue structures that fix the vascular cushions - elastic fibers and submucosal smooth muscle fibers - in the direction of the anal canal. As the disease progresses, the cushions prolapse. In the final stage, the hemorrhoidal plexus consists almost exclusively of connective tissue fibers and a few disordered hypertrophic muscle fibers; the hemorrhoidal prolapse is irreducible. However, the "sliding anal lining" theory offers no pathogenetic explanation for hemorrhoidal disease with recurrent bleeding without a prolapse component.

Classification

Hemorrhoids are classified according to their size and the extent of prolapse into the anal canal or in front of the anus. The Goligher classification has become established internationally:

  • Grade I: only visible proctoscopically, enlarged superior haemorrhoidal plexus - the haemorrhoidal plexuses are pushed through the anal canal during defecation but do not protrude outwards
  • Grade II: Prolapse during defecation with spontaneous retraction
  • Grade III: Prolapse during defecation remains extraanal, but can be digitally reduced
  • Grade IV: permanently fixed, irreducible prolapse

The stage transitions are fluid. In addition, there may be several localizations with different grades and/or an asymmetrical distribution.

Differentiation

A hemorrhoidal prolapse can occur as a solitary nodule or cushion, as multiple nodules/pads or as a circular prolapse. In the case of prolapsed tissue, a distinction is made between

  • pure haemorrhoidal cushions, which are covered exclusively by rectal mucosa and transitional epithelium
  • mixed haemorrhoidal cushions with anoderm, in which the anoderm distal to the haemorrhoidal cushion also prolapses.

The term anoderm prolapse or anal prolapse/hemorrhoidal anal prolapse is used when the anoderm becomes visible outside the anal canal in prolapsing hemorrhoids.

Symptoms

The symptoms of hemorrhoidal disease are uncharacteristic. The main symptom is peranal bleeding, which can occur once, recurrently or continuously over a longer period of time. Bleeding usually occurs during bowel movements or after defecation and can vary in intensity. Bright red bleeding is typical and can vary in intensity. Blood deposits are often found on the toilet paper. Phases of heavy bleeding after each defecation can alternate with bleeding-free intervals lasting weeks or months. In rare cases, bleeding-related anemia is possible.

Caution: Transanal bleeding should always be investigated.

Patients with prolapsing haemorrhoids often suffer from impaired fine incontinence. This can be accompanied by mucous and fecal secretions as well as anal oozing with stool smears and stool-soiled underwear. This often leads to perianal irritation with pruritus and burning. An indirect consequence can be irritant-toxic anal eczema. Severely enlarged hemorrhoids resting on the sphincter muscle often cause a feeling of incomplete evacuation or a permanent urge to defecate.

Pain: Pain is sometimes described as a characteristic of symptomatic haemorrhoids. However, as haemorrhoids are located in the non-sensitive distal rectum, they cannot cause pain from an anatomical point of view. This is rather due to accompanying fissures, thrombosis, edematous marisci, fistulas or an abscess. However, the very rare incarcerated-thombosed hemorrhoidal prolapse can be associated with significant pain.

Diagnosis

The diagnosis of hemorrhoidal disease begins with a basic proctologic examination. This includes a targeted medical history focusing on the type, extent and duration of the symptoms (e.g. bleeding, prolapse, hygiene, diet and fluid intake), a family history of carcinoma (especially colorectal carcinoma) and questions about bowel habits (frequency, consistency, emptying). Further diagnostic focuses are inspection, digital rectal palpation and ano- or proctoscopy.
Note: The hemorrhoidal stage should not be classified as part of a colonoscopy, as this is unreliable by definition (see Goligher classification).

Clinical examination

The clinical examination usually begins with a sensitivity and reflex test (anocutaneous reflex) of the anoderm, for example with a cotton swab. The external sphincter muscle is then palpated in relaxation and during clenching. The function of the levator ani muscle can be tested by asking the patient to pull their finger into the anal canal. To provoke a hemorrhoidal prolapse, the patient must be asked to push.

  • Prolapsing haemorrhoids can be seen after defecation or on examination after the patient has been asked to push. Hemorrhoids that are fixed on the outside and can no longer be repositioned are easily recognizable on inspection. Non-prolapsing hemorrhoids can usually only be seen by ano- or proctoscopy.

Differential diagnoses

Possible differential diagnoses for hemorrhoidal disease are

  • Mariscus or angiofibroma
  • Eczema (most frequently irritant-toxic over-wetting eczema, but also atopic and contact eczema)
  • Anal fissures (DD: Crohn's disease)
  • Anal vein thromboses
  • Abscesses and fistulas (usually as a result of cryptoglandular inflammation of the proctodeal glands)
  • Condylomas
  • Anal carcinomas
  • Oxyuria infections

Therapy

Hemorrhoidal disease can be treated conservatively and surgically. Conservative management includes basic therapy with stool regulation (diet), influencing defecation behavior and possible drug treatment as well as the two non-surgical measures of sclerotherapy and rubber band ligation.

Surgical intervention is used if conservative attempts have been unsuccessful or the extent of the hemorrhoids (grade IV) is very unlikely to respond to conservative treatment.

Note: Primary asymptomatic hemorrhoids should not be treated invasively.

Dietary fiber: A high-fiber diet and stool-regulating measures (Plantago ovata, Indian psyllium husks) have a positive effect in the treatment of symptomatic hemorrhoids.

Stool regulation: Incorrect defecation behavior associated with haemorrhoidal disease should be corrected with the help of trained nursing staff. In addition to an adequate intake of fiber, care should be taken not to force defecation and to avoid straining. In addition, a "session" should not last longer than three minutes. Overall, this can lead to an improvement in symptoms.

Drug therapy: Patients with haemorrhoidal disease may benefit from drug therapy - both for causal treatment and to optimize the post-operative course. The most commonly used drugs are flavonoids such as citrus bioflavonoids, hesperidin, diosmin, rutin and hydroxymethylrutinosides.

Flavonoids (internals): Flavonoids belong to the group of secondary plant substances and were primarily designed as vein remedies. They act as enzyme inhibitors, immune cell activators and radical scavengers. Flavonoid mixtures of diosmin and hesperidin are mainly used. Medicines with this combination include Daflon® Venalex® and Detralex®. Oxerutin (Venoruton®) is available as a hydroxylated flavonoid mixture (rutosides and ß-hydroxyethylrutosides). Deflanin plus® is a combination preparation containing two flavonoids (quercetin and hesperidin) and various vitamins.

Diosmin and hesperidin are said to influence the venous reflux system by increasing the tonicity of veins and venules and thus preventing congestionstimulating lymphogenic activity and thus increasing lymph drainageincreasing capillary resistance and normalizing capillary permeability

Hemorrhoidalia (external agents): These include local anesthetics, corticosteroids, flavonoids and other herbal agents. According to the guideline, they are merely a symptomatic treatment option for possible accompanying symptoms, for example inflammatory or oedematous changes.

Rubber band ligation

Rubber ring or rubber band ligation (GBL) is usually used for grade II hemorrhoids. The hemorrhoidal tissue is grasped by suction via the proctoscope and tied off with a small rubber ring. The dead tissue falls off a few days later, the area scars and shrinks. As a result, excess (hemorrhoidal) tissue is removed and the dislocated anoderm is repositioned at the same time. An interval of 14 days is recommended between two applications. The more ligatures are applied per procedure, the higher the rate of potential complications and side effects, especially pain and bleeding. Possible contraindications include coagulation disorders and the use of potent anticoagulants. To prevent post-interventional pain, patients are given painkillers and local analgesic suppositories. According to the guideline, rubber band ligation should be used as the method of choice for symptomatic second-degree haemorrhoids. For grade 3 and 4 haemorrhoids, GBL is preferable to sclerotherapy due to the better success rate.

Surgical therapy

Surgical treatment of hemorrhoidal disease is indicated if the symptoms cannot be sufficiently alleviated with conservative methods. Surgical interventions are also possible as primary therapy for grade 3 and 4 hemorrhoidal disease if the patient is suffering accordingly. For grade 2 to 3 hemorrhoids, rubber band ligation achieves similarly good short-term results as surgery. GBL should therefore be offered as an alternative to surgery. On the one hand, the surgical procedure shows no advantages over ligation in terms of long-term results. On the other hand, the pain intensity and complication rate are higher after surgery.

Conventional surgical procedures: In conventional surgical procedures, pathologically enlarged hemorrhoidal tissue is resected. Depending on how the resection wound is treated, open and closed procedures can be considered. The choice depends on several factors, including the underlying segmental or circular form of the haemorrhoidal disease:

  • segmental-resecting procedure- open hemorrhoidectomy or Milligan-Morgan (MM) segmental excision
  • closed hemorrhoidectomy or segmental excision according to Ferguson (FG)
  • subanodermal hemorrhoidectomy according to Parks (PA)
  • circular resection procedure - (circular) stapler hemorrhoidopexy according to Longo (CS)

The following points should be noted for the different surgical techniques:

  • The segmental surgical techniques (Milligan-Morgan, Ferguson and Parks) are to be considered equivalent. The stapler procedure should be offered to patients with circular third-degree hemorrhoidal prolapse. It is not recommended for grade IV hemorrhoidal disease due to the higher recurrence rate compared to conventional surgery.

Retraction and ligation procedures

In addition to the classic invasive methods, there are also grasping and ligating procedures. These include Doppler-guided hemorrhoidal artery ligation (Doppler Guided Hemorrhoid Artery Ligation, DGHAL). In DGHAL - other names are Transanal Hemorrhoidal Dearterialization (THD) and Hemorrhoidal Artery Ligation (HAL) - the blood supply to the haemorrhoidal node is reduced by means of bypass ligation of the supposedly supplying haemorrhoidal artery. The artery is located using an ultrasound Doppler device. The Doppler probe is located in a special proctoscope, which also has a guide opening for placing the bypass ligature. This is used to ligate the submucosal arteries in a targeted manner and at a defined distance proximal to the Doppler probe. DGHAL can be performed with or without recto-anal repair (RAR). In Doppler-guided hemorrhoidal artery ligation with RAR, the former is supplemented by a gathering of the enlarged hemorrhoidal tissue.

The guideline advises against the following treatment methods due to high complication rates:

  • Stapled transanal rectal resection (STARR surgery)
  • Anal dilatation
  • Cryotherapy
  • Sphincterotomy (neither in combination with haemorrhoid surgery nor as the sole therapy)

Prognosis

Low-grade hemorrhoids (grade 1-2) can regress spontaneously. Spontaneous freedom from symptoms is possible. If a hemorrhoidal disease is not treated, a progression of symptoms is to be expected - especially in higher stages.

Prophylaxis

Hemorrhoidal disease cannot be prevented. However, simple measures help to minimize the risk of the disease. These include

  • a high-fiber diet
  • an active lifestyle with exercise
  • Sport
  • adequate fluid intake
  • Aim for a normal weight or reduce excess weight
  • avoid straining during defecation
  • Give in to the urge to defecate, do not postpone defecation for too long
  • regular bowel habits