Grade of prolapse and symptoms of haemorrhoids are poorly correlated: result of a classification algorithm in 270 patients

Abstract

Purpose: Haemorrhoid prolapse is an indication for surgery. A correlation between worsening anatomy and increasing symptoms is commonly assumed. We developed a classification algorithm of prolapse and external component, and evaluated its correlation to symptoms before and after surgery.

Method: A study population comprising 180 patients operated for haemorrhoids in a multicentre randomized trial plus a validation set comprising 90 patients operated by us. The classification used three items: (i) patient self-report of prolapse requiring manual reposition; (ii) surgeon assessment of prolapse when patient negated manual reposition; (iii) surgeon assessment of external component. Patient self-reported were rated by frequency (never, 0 points; monthly, 1 point; weekly, 2 points and daily, 3 points). The algorithm yielded three grades: 1, no prolapse; 2, spontaneously reducing prolapse and 3, prolapse needing manual repositioning. The degree of external component was affixed as A, none; B, one or few tags and C, circumferential.

Results: Anatomical grades did not differ between the two sets of patients before or after surgery. Preoperatively, 69% had grade 3 prolapse. Postoperatively, 89% were classified as grades 1A or B. The symptom load was similar for grades 2 and 3; mean 6.5 points preoperatively and 1.8 points postoperatively.

Conclusion: This anatomical classification, based on strict criteria, reliably staged the haemorrhoid prolapse. There was no unique preoperative symptom profile associated with any degree of prolapse with or without an external component. Restored anal anatomy relieved symptoms. The classification also defined recurrence of haemorrhoids.