1. Most cases of hemorrhoids are self-treated by the patient, using topical OTC medication. The condition can resolve spontaneously, especially if the patient takes dietary steps against constipation. Hemorrhoids are far and away the leading cause of rectal bleeding and anal discomfort. They affect about half of us at some point, and frequency increases with age. Most cases are never reported.
2. They’re graded as follows — grade I: painless bleeding, no prolapse; II: self-resolving prolapse, discomfort; III: prolapse that can be manually replaced, some pain; IV: irreducible prolapse, pain, possible thrombosis and strangulation. Discomfort usually comes after defecation, not during — that’s more likely a sign of anal fissure or fistula.
3. An average GP has dozens of patients with grade II hemorrhoids who’ve never mentioned it. Grade II is the least likely to be reported, because the patient generally knows it’s hemorrhoids, whereas grade I bleeding may alarm patients into a consultation.
4. Internal (grade I) hemorrhoids arise from tissue higher in the anal canal, lacking sensory innervation, thus are painless. The bleeding, however, can be substantial, even at first onset of symptoms. It can even produce anemia, like colorectal cancer. A blood count is always a good idea.
5. As everyone knows, hemorrhoidal blood is bright red, not mixed with stool, and typically follows a bowel movement. But bright red blood is not a reason to skip colonoscopy, or at least sigmoidoscopy, especially in older patients. In one series of 604 patients aged over 45 with rectal bleeding who were sent for colonoscopy, 3.4% of those without hemorrhoids had colon cancer — but so did 2% of those with hemorrhoids.
6. The most common OTC ingredient, shark liver oil, is poorly understood and may cause unknown side effects. Other formulations combine a topical anesthetic with an astringent to shrink hemorrhoids.
7. In grade II, the degree and duration of prolapse often depends on the patient’s activity immediately following defecation, because prolapse often occurs over the following half-hour. Sitting down tends to encourage prolapse. Activity can reduce or prevent it. Resting on just one buttock during defecation can lessen prolapse. Arranging bowel movements before bedtime (e.g. with glycerine laxative suppositories) can enable patients to sleep through the prolapse. Many patients appreciate bidets for hygiene.
8. Conservative treatment: start with stool softeners and high-fibre diet. If there’s no resolution, treatment options include: ligation — the commonest and oldest, recommended by Hippocrates himself. Can hurt, but effective in grade II and III. Sclerotherapy (phenol injections): less painful, about 80% effective in grades I to mild III, best done by experienced hand. Infrared coagulation: best reserved for grade I and mild grade II. Cryotherapy: best avoided altogether. Bicap coagulation: grades I to mild III, minor complication rate 10%, recurrence rate 30%.
9. Thrombosed hemorrhoids: local excision is only useful in the first 48-72 hours. Otherwise, sitz or ice baths and analgesia. Thrombosis will resolve after 7-10 painful days.
10. Significant prolapse: these grade III and IV hemorrhoids are treated with either open or closed hemorrhoidectomy (laser or scalpel), or stapled hemorrhoidopexy. Hemorrhoidectomy is painful postoperatively, but has a lower recurrence rate, and is still the gold standard according to Cochrane.
