The Evaluation and Treatment of Hemorrhoids

A Guide for the Gastroenterologist

Robert A. Ganz

Clin Gastroenterol Hepatol. 2013;11(6):593-603.

Grading of Hemorrhoidal Disease

Internal hemorrhoids have been staged or graded on the basis of their severity. The classification of Banov et al^[36] is based on the degree of hemorrhoidal prolapse during defecation (Table 1 and Figure 3). Hemorrhoids can also be classified by their location.^[31] Mixed hemorrhoids arise from both the internal and external plexuses along with their anastomotic connections (Figure 4).^[7,8]

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Figure 3.

Photograph of grade 3 hemorrhoid with prolapse (left) and after manual reduction (right). Courtesy of Iain Cleator, MD, Vancouver, BC, Canada.

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Figure 4.

Illustration of a "mixed" hemorrhoid involving the internal, external, and bridging spaces. Courtesy of Iain Cleator, MD, Vancouver, BC, Canada.

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Table 1. Grades and Types of Hemorrhoids
Grades of internal hemorrhoids (Banov³⁶)
I	Nonprolapsing internal hemorrhoids
II	Internal hemorrhoids prolapse during defecation, spontaneously reduce
III	Internal hemorrhoids prolapse during defecation, must be manually reduced
IV	Internal hemorrhoids prolapsed and incarcerated
Types of hemorrhoids
Internal	Covered by columnar epithelium, Figure 2
External	Covered by squamous epithelium (anoderm), Figure 2
Mixed hemorrhoids	Involving and bridging both of the above spaces, Figure 4

Table 2. Single vs Multiple RBL at a Single Setting
Complication	Single RBL (%)	Multiple RBL (%)
Pain	4.5	29
Vasovagal reflexes	0	5.2
Urinary symptoms	0	12.3
Bleeding	0	11.6
Swelling/edema	0	2.6
Thrombosed external hemorrhoids	0	1.3

NOTE. Adapted from Lee et al.⁶⁴

Table 3. Treatment Options by Grade of Hemorrhoids
	Grade I	Grade II	Grade III	Grade IV	Comments (see text for citations)
Medical management	X	X	X	X	May provide symptomatic relief as well as lessen likelihood of recurrence.
Sclerotherapy	X	X			Limitations with prolapse and complications discussed.
IRC	X	X			Best suited to smaller hemorrhoids, need for more frequent treatments, higher recurrence rates.
Bipolar/heater probe coagulation	X	X			Heater probe with quicker results, but more pain; bipolar with more overall complications.
Direct current therapy (Ultroid)	X	X	X		Limited by time required for therapy.
RBL	X	X	X		Current first-line therapy in I, II, and III. Pain most frequent complication, can be minimized by proximal placement, touch technique, single banding at a session.
Cryosurgery/anal dilatation (Lord's)	NA	NA	NA	NA	Complications prohibitive
Surgery		(X)	(X)	X	For use in patients unresponsive to lesser treatments. More effective than RBL in grade III, but pain/disability caused by surgery leads to recommendation of attempting RBL or IRC first and saving surgery for resistant cases.