Still a Case of "No Pain, No Gain"? An Updated and Critical Review of the Pathogenesis, Diagnosis, and Management Options for Hemorrhoids in 2020

Abstract

The treatment of haemorrhoids remains challenging: multiple treatment options supported by heterogeneous evidence are available, but patients rightly demand a tailored approach. Evidence for newer surgical techniques that promise to be less painful has been conflicting. We review the current evidence for management options in patients who present with varying haemorrhoidal grades. A review of the English literature was performed utilizing MEDLINE/PubMed, Embase, and Cochrane databases (31 May 2019). The search terms (haemorrhoid OR haemorrhoid OR haemorrhoids OR haemorrhoids OR "Hemorrhoid"[Mesh]) were used. First- and second-degree haemorrhoids continue to be managed conservatively. The easily repeatable and cost-efficient rubber band ligation is the preferred method to address minor haemorrhoids; long-term outcomes following injection sclerotherapy remain poor. Conventional haemorrhoidectomies (Ferguson/Milligan-Morgan/Ligasure haemorrhoidectomy) still have their role in third- and fourth-degree haemorrhoids, being associated with lowest recurrence; nevertheless, posthaemorrhoidectomy pain is problematic. Stapled haemorrhoidopexy allows quicker recovery, albeit at the costs of higher recurrence rates and potentially serious complications. Transanal Haemorrhoidal Dearterialization has been promoted as nonexcisional and less invasive, but the recent HubBLe trial has questioned its overall place in haemorrhoid management. Novel "walk-in-walk-out" techniques such as radiofrequency ablations or laser treatments will need further evaluation to define their role in modern-day haemorrhoid management. There are numerous treatment options for haemorrhoids, each with their own evidence-base. Newer techniques promise to be less painful, but recurrence rates remain an issue. The balance continues to be sought between long-term efficacy, minimisation of postoperative pain, and preservation of anorectal function.

Keywords: Disease management; Haemorrhoidectomy; Haemorrhoids; Rectal diseases; Surgical procedure.

Fig. 1.

(A) Thrombosed prolapsed internal haemorrhoid. (B) Complex thrombosed external haemorrhoid, which was found to have spontaneously discharged - this was managed by excision of the thrombus and its underlying external haemorrhoidal plexus.

Fig. 2.

Rubber band ligation. The target tissue is the apex of the haemorrhoid, well above the dentate line.

Fig. 3.

An open haemorrhoidectomy wound, seen using a Fansler proctoscope. The fibres of the external and internal sphincter muscles are identified and preserved. In this patient, only a single pedicle haemorrhoidectomy was performed.

Fig. 4.

Bilateral advancement anoplasty flaps. This patient had severe anal stenosis following a previous 3 pedicle haemorrhoidectomy. (A) Bilateral island flaps are raised close to the anal verge, and (B) utilized as anocutaneous advancement flaps.

Fig. 5.

Stapled haemorrhoidopexy. (A) This patient presented with circumferential third-degree haemorrhoids. (B) Following application of a mucosal pursestring suture, the PPH-03 stapler is positioned. (C) The stapler is fired. (D) The excised rings of rectal mucosa are inspected. (E) The staple line is inspected for any defects or bleeding. (F) Immediately following stapled haemorrhoidopexy, the prolapsed haemorrhoidal tissue is observed to have reduced substantially.

Fig. 6.

Transanal haemorrhoidal dearterialization. (A) A transanal haemorrhoidal dearterialization proctoscope with doppler transducer is positioned, on this occasion localising the superior rectal artery branch at 7 o’clock. (B, C) 3-0 vicryl suture ligation of vessel through the window of the proctoscope.