Almost everyone suffers from hemorrhoids at some time in their lives. The symptoms include bleeding, prolapsing tissue, fullness after defecation, and pain. Bleeding can mimic or mask the diagnosis of cancer and must be thoroughly evaluated. In most cases, however, swift, simple, and effective treatment can be given in an outpatient clinic or a health center. The key to understanding the feasibility of outpatient treatment is that there are no sensory nerve fibres above the dentate (pectinate) line in the anus, which is at the squamomucosal junction. Internal hemorrhoids arise above this line, so they can be treated without an anesthetic. External hemorrhoids develop below the dentate line and are exquisitely sensitive. Little preparation is needed for the treatment of internal hemorrhoids, but an enema will make them easier to see as well as making the procedure more aesthetically acceptable.

Hemorrhoids are graded by the degree of prolapse, and this grading determines the most appropriate methods of treatment. First-degree hemorrhoids are merely visible vessels, second-degree lesions prolapse with defecation but return spontaneously, third degree lesions prolapse and require manual replacement, and fourth degree lesions remain prolapsed out of the anal canal despite attempts to reduce them.

The treatment choices for internal hemorrhoids include infrared coagulation, radio-frequency coagulation, direct current coagulation, rubber band ligation, sclerotherapy, cryosurgery, scalpel surgery and laser surgery. Scalpel surgery is generally reserved for advanced fourth degree hemorrhoids and is most often done on inpatients. Laser surgery is said to be less painful, but this has proved difficult to verify. Sclerotherapy is usually indicated only in first and second-degree lesions and in the United States it is now little used because of the frequency and severity of complications and the technical difficulties of proper placement of the sclerosant. A recent report in the BMJ described three patients who became permanently impotent after sclerotherapy for their hemorrhoids. Cryotherapy is also little used because of the profuse and prolonged discharge and the complications such as excessive sloughing and sphincter injury, and the poor results.

The least expensive and possibly the most widely used equipment is a rubber band ligator. This is suitable for first to third degree hemorrhoids. The bands are easy to apply, but the drawback is that two people are needed, one to hold the anoscope and the other to apply the bands. The treatment can cause severe pain if the bands are placed too low, and there is a small risk of perineal sepsis, which can, very rarely, be fatal. Sepsis is a medical emergency signaled by fever, pain, swelling, and the inability to pass urine.

Learn about the IRC Procedure from Dr. Alicia Hall

The infrared coagulator is gaining rapid acceptance for outpatient treatment of internal first and second-degree hemorrhoids and some third degree. A special bulb provides high intensity infrared light that coagulates vessels and tethers the mucosa to subcutaneous tissues. The flat tip probe measures 6 mm in diameter and is applied for 1.5 – 2 seconds three to eight times to a localized area of hemorrhoids. Generally only one section of the hemorrhoids is treated per visit. Patients generally have two to four areas that need treatment and so have to return several times at weekly to monthly intervals until all have been controlled. Infrared coagulation is quick (10-15 minutes a visit), effective, and painless, and patients can return to work immediately or the next day. Eighty three percent of patients treated by this method are reported to be free of symptoms at three months. In a meta-analysis comparing infrared coagulation, rubber band ligation, and injection sclerotherapy, infrared coagulation came out best.

The radio-frequency coagulation unit uses a disposable probe with an electrical current flowing between two flat electrodes (positive and negative) aligned at the tip. Activating the unit for two seconds in three or four areas of the same hemorrhoid complex effectively coagulates the vessels. Although the manufacturer claims that all hemorrhoids present can be treated in a single session, I believe it is preferable to treat one area at a time to avoid excessive pain and bleeding.

The direct current units use a probe with two sharp points as electrodes. They are promoted for use in all grades of hemorrhoids but seem to have two drawbacks. Firstly, each treatment takes eight to 12 minutes of probe contact; this is considerably longer than the six to 110 seconds required for infrared and radio frequency units. Secondly, the probes can penetrate deeply unless the operator is careful to stabilize them during treatment.

Whatever treatment is used, postoperative management is the same. The goal is to keep patients stools soft by giving a high bulk diet and lots of fluids. Non-steroidal anti-inflammatory drugs will usually control any discomfort. Sitz baths may help in rare cases where needed and Suppositories are rarely necessary.

The clear advantages of the modern methods for outpatient treatment of internal hemorrhoids are that they are quick and relatively painless. Patients lose little if any time from work, the complications are minor, and the cure rates are high.

Patients may have a little spotting of blood for a few days and slightly more bleeding may occur after 10-14 days, when the scar sloughs, but major hemorrhages do not occur as in the old style surgical approaches. No episodes of perineal sepsis, death, or impotence have been reported with the newer methods. The failure rates are reported to be 10-20%, but all that is needed is further treatment. A complication seen in 1-2% of patients (but not reported in the literature) is external Hemorrhoidal thrombosis, usually associated with treatment of too extensive an area of internal hemorrhoids at one visit.

Formal surgical intervention is still occasionally necessary, but patients dislike it because of the associated severe pain and morbidity. Doctors working in primary care may master modern treatment methods, and they provide a prompt effective treatment in most cases.

John L Pfenninger, Director The National Procedures Institute, Midland, Michigan 48640, USA

For more information about the IRC procedure, we have provided links to the following resources:

The American Gastroenterological Association
Mayo Clinic
UpToDate Patient Information