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Learning objectives
Describe the anatomy and causes of internal
hemorrhoids.
Identify clinical signs and symptoms of internal
hemorrhoids.
Describe treatment options and associated complications
for symptomatic hemorrhoids.
I
nternal hemorrhoids are a normal part of human
anatomy, but symptomatic hemorrhoids are one of FIGURE 1. Internal and external hemorrhoids
the most common complaints encountered in a med-
ical office. Painless rectal bleeding and prolapsed tissue have become more commonplace because they cause less
are the most common internal hemorrhoidal symptoms, postoperative pain and patients recover more quickly.
can occur at any age, and affect both sexes. An estimated
50% of the population over age 50 years have experienced ANATOMY AND CAUSES
hemorrhoidal symptoms at some point in their lives.1 The Internal hemorrhoids are normal vascular cushions in the
rich, low-fiber Western diet leads not only to an increase anal canal proximal to the dentate line (Figure 1). They
in heart disease and diabetes but also poor bowel habits are located in the submucosa, and are insensate. Bleeding
such as constipation, one of the most common causes of from internal hemorrhoids typically is painless. Hemor-
hemorrhoidal disease.1,2 Conservative treatment or non- rhoids are supplied arterially by the superior, middle, and
operative management of internal hemorrhoids with inferior hemorrhoidal arteries, and drain venously via the
dietary fiber and noncaffeinated fluids can improve hem- middle rectal veins to the internal iliac veins. Coughing or
orrhoidal symptoms.2 straining leads the internal hemorrhoids to engorge with
When conservative treatment fails, surgery is needed blood, helping maintain continence. The anal sphincter
to improve the patients quality of life. Though the con- does not completely close at rest, and about 20% of rest-
ventional hemorrhoidectomy is successful, newer tech- ing anal pressure comes from hemorrhoids.3 Recognizing
niques such as the stapled hemorrhoidopexy for prolapsed that internal hemorrhoids are a normal anatomic finding
hemorrhoids and transanal hemorrhoidal dearterialization is essential when deciding if surgery is the correct treatment
plan.1,2 Surgical intervention is not supported for asymp-
tomatic hemorrhoids; treatment should be targeted to the
Rochelle Paris Kline practices in the Department of Surgical Oncology
at the University of Pittsburgh (Pa.) Medical Center. The author has patients complaint.
disclosed no potential conflicts of interest, financial or otherwise. The most common factors that contribute to symptom-
DOI: 10.1097/01.JAA.0000459809.87889.85 atic hemorrhoidal disease are:
Copyright 2015 American Academy of Physician Assistants irregular bowel movements (constipation or diarrhea)
COMPLICATIONS
Surgery for internal hemorrhoids can cause bleeding, infec-
tion, urinary retention, fecal incontinence, or anal stenosis.
Rates of complications are comparable regardless of the
type of surgery.
Bleeding can be controlled with packing of the anal
canal or suturing.2 Infection is rare, but can lead to sep-
ticemia if not recognized early and treated with IV anti-
biotics.19 Urinary retention usually resolves within 72
hours once initial postoperative edema subsides, and can
be treated with temporary catheterization.20 Fecal incon-
tinence can be treated initially with bulk-forming agents
such as oral fiber supplements; the anus has greater
control with formed stool compared with loose stool.2
Anal stenosis can be treated with anal dilations in the
office or OR.20
FIGURE 3. Examination after transanal hemorrhoidal
dearterialization
CONCLUSION
statistical differences in pain, pruritus, and urgency Because hemorrhoids are a normal part of our anatomy,
among hemorrhoidopexy patients compared with those their presence does not always warrant treatment. As
who had had conventional hemorrhoidectomy. The with all disease processes, the history and physical exam-
studies reviewed greater than 1-year follow-up of 628 ination is imperative to guiding treatment and determin-
patients.12 In addition, the Cochrane review and another ing if further workup is warranted to rule out neoplasia
study published in 2011 found that patients who had or other disease processes. Newer operative techniques
hemorrhoidopexy had an elevated rate of long-term for internal hemorrhoids such as a hemorrhoidopexy or
recurrence of hemorrhoids compared with patients who dearterialization may reduce postoperative pain and
had conventional hemorrhoidectomy.8,12 speed recovery. Overall complications of hemorrhoid
Specific postoperative complications related to the stapling surgery are comparable, but when they occur can be
mechanism include rectal perforation, rectovaginal fistula, devastating. JAAPA
and staple line bleeding.2 A diverting temporary stoma
may be required.13 In general, the rate of complications
Earn Category I CME Credit by reading both CME articles in this issue,
such as fever, fecal incontinence, urinary retention, and
reviewing the post-test, then taking the online test at http://cme.aapa.
anal stenosis was the same.10,14 org. Successful completion is defined as a cumulative score of at
least 70% correct. This material has been reviewed and is approved
TRANSANAL HEMORRHOIDAL DEARTERIALIZATION for 1 hour of clinical Category I (Preapproved) CME credit by the
A new approach introduced in 1995, transanal hemor- AAPA. The term of approval is for 1 year from the publication date of
February 2015.
rhoidal dearterialization, uses an anoscope with ultrasound
to identify the six branches of the superior rectal artery
that are located above the dentate line. Ligation of the REFERENCES
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