Hemorrhoids are swollen and inflamed veins located in and around the anus and lower rectum. These vascular cushions are a normal part of the anatomy, but when they enlarge due to increased pressure, they can cause symptoms like pain, itching, and bleeding. Hemorrhoidal disease is common, affecting approximately half of all adults by the age of 50. Treatment depends on an accurate diagnosis of the hemorrhoid’s location and severity, which is graded on a scale from I to IV.
Initial Diagnosis and Care Providers
A patient’s journey to diagnosis begins with a primary care provider (PCP), such as a family doctor or internist. The PCP performs an initial assessment and triage, often involving a visual examination of the anal area. For internal hemorrhoids, a digital rectal exam or anoscopy may be used to assess the size and location of the swelling.
For mild cases (Grade I and some Grade II), the PCP recommends conservative management. This treatment focuses on lifestyle adjustments, including increasing dietary fiber and fluid intake to soften stools and reduce straining. Over-the-counter topical creams, suppositories, and sitz baths may be suggested to alleviate discomfort. If symptoms do not improve after a week, or if the hemorrhoids are more advanced, a referral to a specialist is necessary.
Specialists Qualified to Perform Removal
The two types of specialists qualified to manage and remove hemorrhoids are Gastroenterologists and Colorectal Surgeons. Gastroenterologists specialize in the entire digestive system, from the esophagus to the rectum. They frequently perform initial diagnostic procedures and office-based, non-surgical removal treatments.
Colorectal Surgeons possess specialized training in diseases of the colon, rectum, and anus. They are qualified to manage all stages of hemorrhoidal disease, including performing both minimally invasive procedures and definitive surgical interventions. A Colorectal Surgeon is the preferred choice for advanced cases (Grade III and IV) or when an office-based procedure has failed.
Minimally Invasive Removal Procedures
Minimally invasive procedures are reserved for Grade I and II internal hemorrhoids and are performed in an outpatient or office setting. These treatments are designed to cut off the blood supply to the hemorrhoid, causing it to shrink and wither away.
Rubber Band Ligation (RBL)
RBL is the most common technique, where a small rubber band is placed around the base of the internal hemorrhoid. This cuts off the blood flow, and the hemorrhoid tissue, along with the band, falls off within about a week.
Sclerotherapy
Sclerotherapy involves injecting a chemical solution directly into the hemorrhoid tissue. The solution causes the vein to scar and collapse, reducing the size of the hemorrhoid. While causing little to no pain, sclerotherapy may be less effective than RBL and sometimes requires multiple treatment sessions.
Infrared Coagulation (IRC)
IRC uses a small probe that emits a focused beam of infrared light. The heat creates scar tissue that blocks the blood flow, causing the hemorrhoid to shrivel and recede. This method is well-suited for smaller, bleeding internal hemorrhoids and is known for its simplicity and quick recovery.
Surgical Intervention Options
Surgical intervention is reserved for large, prolapsed hemorrhoids (Grade III and IV) or for cases that have not responded to minimally invasive techniques.
Excisional Hemorrhoidectomy
This is the most traditional method, where the surgeon removes the excess tissue that causes the bleeding and swelling. This procedure is highly effective and complete, but it is performed in an operating room, often under general or spinal anesthesia. Recovery from a traditional hemorrhoidectomy can be lengthy, often taking two to four weeks, with significant post-operative pain managed by medication.
Stapled Hemorrhoidopexy (PPH)
This alternative approach uses a circular stapling device to remove a ring of tissue above the hemorrhoid. This action lifts the remaining hemorrhoidal tissue back into its normal position. Because this procedure is performed in an area with fewer nerve endings, it results in less post-operative pain and a quicker return to normal activities, often within seven to ten days. While PPH offers a faster recovery, it carries a slightly higher risk of recurrence compared to an excisional hemorrhoidectomy.