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“The Lord will strike you with the boils of Egypt, and with hemorrhoids of which you cannot be healed.” Deuteronomy, Chapter 28, verse 27.

Hemorrhoids also called “piles” have been around since our species learned to walk upright. They’re annoying vascular swellings that itch, bleed, prolapse and thrombose. Even though they’re as old as man, there’s little agreement on their nature, pathophysiology and treatment.

In medical school we’re taught that hemorrhoids are varicose veins of the rectum, brought on by conditions that increase abdominal pressure (e.g. pregnancy), raise portal pressure (cirrhosis), or simply by poor washroom habits, such as sitting too long on the toilet and allowing the exertion of downward pressure, forcing the hemorrhoidal tissue to protrude.

But piles aren’t varicose veins at all, e.g. they don’t look or bleed like veins. True varicose veins of the rectum very much resemble their counterparts in the lower extremities or the esophagus.

What’s more, hemorrhoids have been found in stillborns and infants two groups that don’t exhibit any of the factors that supposedly cause them.

The truth is, hemorrhoids aren’t such evil things. They act as vascular cushions and are part of the continence mechanism of the anorectum. When you contemplate their universal prevalence, you realize that they actually cause trouble only occasionally: it’s been estimated that 10% of the adult population suffers at least once in their lifetime from hemorrhoids.

Alvin Newman, MD, FRCPC, FACG, FACP is Adjunct Professor of Medicine at the University of Toronto and Attending Gastroenterologist at Mount Sinai Hospital, Toronto.

A. Diagnosis and staging

1. Visual inspection will do if they’re prolapsed
2. Otherwise, use an anoscope
3. Classification:
   • based on whether or not they easily retreat into the anal canal
   • independent of bleeding
   • stage I can only be seen with an anoscope
   • stage II may prolapse with defecation but reduce spontaneously
   • stage III will only reduce if the patient pushes them back in
   • stage IV permanently prolapsed.

B. Treatment Considerations

1. Stages I and II seldom merit treatment other than with over-the-counter suppositories, ointments and warm-water sitz baths
2. Stages III and IV need more serious treatment (see below)
3. In the case of bleeding hemorrhoids, consider concomitant presence of serious pathology more proximally in the colon
4. Patients over 50 with rectal bleeding must get a colonoscopy
5. If considering rubber-band ligation, differentiate between internal (above the dentate line) and external (below the dentate line) hemorrhoids
6. Never shoot a rubber-band around a skin-covered structure.

C. Pathophysiology

1. The double nomenclature “hemorrhoids” and “piles” underscores the fact that they may either bleed or become easily identifiable as palpable masses
2. Hemorrhoids are vascular and fill with blood
3. Their tumescent state is good for continence
4. Normally, they disgorge their blood build-up from time to time
5. In this sense, we are dealing with erectile tissue not unlike the corpus cavernosum of the penis
6. The difference is that hemorrhoids are surrounded by the internal anal sphincter, which is not under conscious cortical control

D. Bleeding

1. Frequently caused by straining
2. Manage by diminishing straining during defecation
   • take careful inventory of the patient’s medications and try to eliminate the constipating ones
   • many of the most popular analgesic, psychoactive and antiparkinsonian drugs are highly constipating
   • there’s evidence from meta-analyses that high-fibre diets may decrease episodes of bleeding

E. Relief from the itch

1. Itchy hemorrhoids (anal pruritus) are invariably associated with skin irritation
2. May respond to short-term use of 1% hydrocortisone cream applied 2-3 times daily
3. Warm sitz baths twice-daily can be highly beneficial and may not only have a soothing effect, but also lower elevated anal sphincter pressure.

Nearly 1,000 years ago, the eminent medieval philosopher / physician Moses Maimonides wrote a treatise on hemorrhoids, suggesting the use of poultices of chicken fat and saffron to relieve symptoms.

In the 21st century, one of the most popular brands of soothing suppositories, Anusol, is made mainly of cocoa butter one could say that the transition from chicken fat to cocoa butter doesn’t exactly represent a giant leap of progress in a millennium.

F. Thrombosis

1. If the hemorrhoids engorge and the sphincter contracts mightily, the trapped blood will have no easy exit and eventually may thrombose
2. This is painful in the extreme and is usually treated by an incision and clot-evacuation a technique that provides instant relief
3. A thrombosed hemorrhoid is the anal equivalent of a priapism, and the treatment is similar to the extreme measures occasionally undertaken in the relief of priapism
4. Thrombosed hemorrhoids occur more frequently than priapisms because there’s no sphincter around the penis, unless one is using a ring-like sex toy
5. Stress as well as fissures and other factors may induce sphincter spasm, so thrombosed hemorrhoids may be a functional gastrointestinal disorder
6. Almost all patients with symptomatic hemorrhoids have increased anal sphincter pressure
7. Many techniques used in the management of hemorrhoids involve some measure to reduce sphincter pressure.

G. Aggressive treatment

1. Stage III hemorrhoids
   • Rubber band ligation is first-line treatment
   • This can be done in the office with acceptably low morbidity and about an 80% success rate
   • Infrared coagulation and other tissue destructive techniques are less widely used.
2. Stage IV hemorrhoids
   • Respond only to surgical hemorrhoidectomy
   • In parts of Canada, there’s only limited availability of proficient and experienced surgeons willing to perform the operation, as there’s a lack of availability of operating room time
   • Improvement of this situation may take a substantial public outcry.

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