Anal Canal

Importance Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US. Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse.

Observations Hemorrhoids are classified as internal, external, or mixed (concurrent internal and external hemorrhoidal disease). Internal hemorrhoids originate above the dentate line, the boundary between the upper and lower anal canal, and may cause rectal bleeding, discomfort, and tissue prolapse from the anal canal. Internal hemorrhoid prolapse is classified as grade I (into anal canal), grade II (beyond the anus with spontaneous reduction), grade III (requiring manual reduction), and grade IV (irreducible). External hemorrhoids, arising below the dentate line, cause rectal pain when engorged or thrombosed. Initial treatment of all hemorrhoidal disease involves increasing intake of dietary fiber and water and avoiding straining during defecation. Phlebotonics (eg, flavonoids [thought to improve venous tone]) reduce bleeding, rectal pain, and swelling, although symptom recurrence reaches 80% within 3 to 6 months after treatment cessation. If dietary modification and phlebotonics are ineffective, grade I to grade III internal hemorrhoidal disease can be treated with office-based interventions. Rubber band ligation—placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow—resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%. Sclerotherapy, which induces fibrosis with a sclerosant injection, is efficacious in the short term (weeks to months) among 70% to 85% of patients, but long-term remission occurs in only one-third of patients. Infrared coagulation uses heat to coagulate hemorrhoidal tissue, yielding 70% to 80% success in reducing bleeding and prolapse. Excisional hemorrhoidectomy, for disease unresponsive to office-based therapy or for mixed hemorrhoidal disease, achieves low recurrence (2%-10%), although with longer recovery (9-14 days). External hemorrhoidal disease rarely requires surgery unless acutely thrombosed. Outpatient clot evacuation within 72 hours of onset of a thrombosed external hemorrhoid is associated with decreased pain and reduced risk of repeat thrombosis. Patients presenting more than 72 hours after external hemorrhoid acute thrombosis should receive medical treatment (eg, stool softeners, oral and topical analgesics such as 5% lidocaine).

Conclusions and Relevance Hemorrhoidal disease affects 10 million people in the US. First-line treatment is increased fiber intake, avoidance of straining during defecation, and phlebotonics. In-office rubber band ligation for grade I to III internal hemorrhoid disease is first-line procedural treatment for persistent symptoms despite conservative therapies. Excisional hemorrhoidectomy is recommended for grade III to IV prolapse, thrombosis, or mixed hemorrhoidal disease that does not improve with less invasive approaches.

Author/s:

Jean H. Ashburn

Hemorrhoidal Disease: A Review

Megan George — Tue, 19 Aug 2025 16:12:53 +0000

Date Added:

August 19, 2025

Journal/Publication:

JAMA

Publication Date:

August 18, 2025

URL:

Hemorrhoidal Disease: A Review

Format:

Article

DOI (1):

10.1001/jama.2025.13083

Keywords

Gastroenterology

colorectal

hepatology

PMID (1):

40824576

MeSH

Pelvic Organ Prolapse* / surgery

A review of the diagnosis and management of patients with hemorrhoids. James W. Mold, MD, MPH

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Author/s:

Jean H Ashburn

Topical treatments for anal fissure

Aubrey Delammermore — Sat, 28 Jan 2023 06:00:00 +0000

Date Added:

January 28, 2023

Journal/Publication:

Canadian Family Physician

Publisher:

College of Family Physicians of Canada

Publication Date:

January 1, 2023

Issue:

Volume:

Pages:

URL:

Topical treatments for anal fissure

Type:

Meta-analyses, Reviews, and Guidelines

Format:

Article

DOI (1):

10.46747/cfp.690133

Keywords

Treatment Outcome

vasodilator agents / therapeutic use

nitroglycerin

vasodilator agents

anal fissure

PMID (1):

36693740

MeSH

Anal Canal

Administration, Topical

chronic disease

Fissue in Ano* / Drug therapy

Nitroglycerin / therapeutic use

A summary of the effectiveness of various typical treatments of patients with anal fissures. James W. Mold, MD, MPH

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Clinical question
How effective are topical treatments (calcium channel blockers [CCBs], nitrates, and vitamin E) for
chronic anal fissures in adults?
Bottom line
Healing rates with topical nitroglycerin are roughly
60% versus 40% with placebo at 8 weeks. Topical
CCBs are at least as good as nitroglycerin, with a
lower risk of headache (7% versus 56%). Based on
1 RCT, topical vitamin E may be superior to nitroglycerin (86% versus 66% healed at 8 weeks).

Author/s:

Fagan, C., Kolber, M. R., Lindblad, A. J.