PRACTICE PARAMETERS

Practice Parameters for the Management of

Hemorrhoids (Revised 2010)
David E. Rivadeneira, M.D. Scott R. Steele, M.D. Charles Ternent, M.D.
Sridhar Chalasani, M.D. W. Donald Buie, M.D.
Janice L. Rafferty, M.D., on behalf of the Standards Practice Task Force of
The American Society of Colon and Rectal Surgeons

he American Society of Colon and Rectal Surgeons paramount importance for all those treating patients with

T is dedicated to assuring high-quality patient care by

advancing the science, prevention, and manage-
ment of disorders and diseases of the colon, rectum, and
hemorrhoids to have a clear understanding of the evalua-
tion and management of this disease process. These guide-
lines address both the diagnostic and therapeutic modali-
anus. The Standards Committee is composed of Society ties in the management of hemorrhoidal disease.
members who are chosen because they have demonstrated
expertise in the specialty of colon and rectal surgery. This Methodology
Committee was created to lead international efforts in de- These guidelines are built on the last set of the American
fining quality care for conditions related to the colon, rec- Society of Colon and Rectal Surgeons (ASCRS) Practice
tum, and anus. This is accompanied by developing Clinical Parameters for the management of hemorrhoids published
Practice Guidelines based on the best available evidence. in 2005.2 A literature search of MEDLINE, PubMed, and
These guidelines are inclusive, and not prescriptive. Their the Cochrane Database of Collected Reviews was per-
purpose is to provide information on which decisions can formed through April 2010. Key word combinations in-
be made, rather than dictate a specific form of treatment. cluded hemorrhoid, internal and external hemorrhoids,
These guidelines are intended for the use of all practitio- hemorrhoid disease, thrombosed hemorrhoid, rubber
ners, health care workers, and patients who desire infor- band ligation, hemorrhoidopexy, hemorrhoidectomy,
mation about the management of the conditions addressed PPH, Milligan-Morgan, Ferguson, Doppler guided, and sta-
by the topics covered in these guidelines. It should be rec- pled hemorrhoidopexy. Directed searches of the embedded
ognized that these guidelines should not be deemed inclu- references from the primary articles were also performed in
sive of all proper methods of care or exclusive of methods selected circumstances. The final grade of recommendation
of care reasonably directed to obtaining the same results. and level of evidence for each statement was determined
The ultimate judgment regarding the propriety of any spe- by the use of the Grades of Recommendation, Assessment,
cific procedure must be made by the physician in light of all Development, and Evaluation (GRADE) system.3
of the circumstances presented by the individual patient.
Recommendations
Statement of the Problem 1. The evaluation of patients with hemorrhoids should
With more than 10 million patients experiencing hemor- include a directed history and physical examination.
rhoidal symptoms, hemorrhoids represent one of the most Grade of Recommendation: Strong recommendation
common medical and surgical disease processes encountered based on low-quality evidence 1C
in the United States. It is estimated that more than 50% of the The diagnosis of hemorrhoids is almost always a clin-
population over 50 years of age have experienced hemorrhoid ical one. The initial assessment should include a thorough
problems.1 Unfortunately, many anorectal conditions are in- targeted history and physical examination, with focus on
appropriately attributed to hemorrhoids; therefore, it is of the extent, severity, and duration of symptoms, such as
bleeding, prolapse, issues of hygiene and pain, and fiber
and fluid intake, as well. In addition, a careful review of
Key Words: Hemorrhoids; Hemorrhoid banding; Thrombosed external bowel habits including frequency, consistency, and ease of
hemorrhoids; Hemorrhoidectomy. evacuation should be performed. All patients with rectal
Dis Colon Rectum 2011; 54: 1059 1064
bleeding require a detailed family history with particular
DOI: 10.1097/DCR.0b013e318225513d emphasis on intestinal disease. The presence of malignant
The ASCRS 2011 conditions should be evaluated to assess for sporadic or
DISEASES OF THE COLON & RECTUM VOLUME 54: 9 (2011) 1059
1060 RIVADENEIRA ET AL: PRACTICE PARAMETERS FOR HEMORRHOIDS

time on the commode, because this has been associated

TABLE 1. Classification of internal hemorrhoids
with higher rates of symptomatic hemorrhoids.12
Grade Physical findings 4. Most patients with grade I, II, and III hemorrhoid
I Prominent hemorrhoidal vessels, no prolapse disease in whom medical treatment fails may be effec-
II Prolapse with Valsalva and spontaneous reduction tively treated with office-based procedures, such as
III Prolapse with Valsalva requires manual reduction
banding, sclerotherapy and infrared coagulation. Hem-
IV Chronically prolapsed manual reduction ineffective
orrhoid banding is typically the most effective option.
Grade of Recommendation: Strong recommendation
based on moderate-quality evidence 1B
hereditary colon and rectal cancer, and thus for the need The goals of all office-based procedures are 3-fold: to
for extended colonic evaluation.4 decrease vascularity, reduce redundant tissue, and increase
The physical examination should typically include vi- hemorrhoidal fixation to the rectal wall to minimize pro-
sual inspection of the anus, digital examination, and anos- lapse. These procedures are all relatively well tolerated,
copy and/or proctoscopy looking for evidence of throm- causing minimal pain and discomfort. However, patients
bosis or concomitant anorectal pathology, such as fissure, should understand they all have a variable recurrence rate
fistula, abscess, or evidence of Crohns disease.5 Internal hem- and may require repeated applications.1315
orrhoids, located above the dentate line, can be assigned a
grade based on the definitions in Table 1, which will help to Rubber Band Ligation. Rubber band ligation is a com-
guide therapy. Laboratory evaluation is not typically required. monly used and effective way of treating symptomatic in-
2. Complete endoscopic evaluation of the colon is ternal hemorrhoids. In a meta-analysis of 18 randomized
indicated in select patients with hemorrhoids and rectal prospective studies, rubber band ligation was superior to
bleeding. Grade of Recommendation: Strong recom- injection sclerotherapy and infrared coagulation in the
mendation based on moderate-quality evidence 1B treatment of grades I, II, and III hemorrhoids in terms of
Although commonly associated with hemorrhoids, the need for repeated treatments. However, the risk of
complaints of rectal bleeding may be a symptom of other complications, albeit small, and pain tended to be greater
disease processes, such as colorectal cancer, inflammatory for rubber band ligation in comparison with the other mo-
bowel disease, other colitides, diverticular disease, and an- dalities.13 Rubber band ligation has also been directly com-
giodysplasia.6 A thorough personal history, a detailed fam- pared with excisional hemorrhoidectomy for grade III
ily history, and a physical examination, which may include hemorrhoids. A systematic review of randomized con-
proctoscopy and/or flexible sigmoidoscopy, will identify trolled trials found that, overall, it was less effective and
high-risk patients requiring more extensive evaluation. more likely to require multiple procedures than surgical
Those who fulfill the select criteria should have a full co- excision. However, rubber band ligation was associated
lonic evaluation with colonoscopy. Patients unable to un- with less pain and fewer complications than the operative
dergo colonoscopic evaluation may be considered for flex- approach.16 A recent Cochrane review by the same group
ible sigmoidoscopy combined with barium enema or reported that band ligation may be the preferred choice for
other diagnostic modalities per consensus guidelines.7 grade II hemorrhoids, and even considered for first-line
3. Dietary modification consisting of adequate fluid therapy in grade III hemorrhoids, whereas surgical exci-
and fiber intake is the primary first-line nonoperative sion may be more appropriately reserved for grade III or
therapy for patients with symptomatic hemorrhoid rubber band treatment failures.17
disease. Strong recommendation based on moderate- Banding is commonly performed with either a suction
quality evidence 1B apparatus or a forceps ligator. In direct comparison, suc-
Constipation and altered bowel habits can play a sig- tion ligation of second- and third-degree hemorrhoids was
nificant role in many patients with symptomatic hemor- noted to be beneficial in comparison with forceps ligation
rhoids. Whereas more aggressive office-based or operative in terms of pain tolerance, use of analgesics, and intrapro-
treatment is usually required for advanced hemorrhoidal cedural bleeding.18 However, both methods are accept-
disease (grades III to IV or those with significant external able, because, in general, banding is very well tolerated.
components), increased fiber and fluid intake has been The most common complications are postband anorectal
shown to improve symptoms of mild to moderate prolapse pain, rectal bleeding, thrombosed external hemorrhoids,
and bleeding. A Cochrane review of 7 randomized studies and vasovagal symptoms, which have been reported in
including 378 patients demonstrated a benefit in both the 1% to 3% of patients.19,20 A careful and detailed history
reduction of symptomatic prolapse (RR 0.53, 95% CI should be specifically obtained from the patient in regard
0.38 0.73) and bleeding (RR 0.50, 95% CI 0.28 0.89) to the presence of coagulation disorders, either intrinsic,
in patients with increased fiber intake.8 11 Patients should such as those with thrombocytopenia, or acquired, as seen
also be counseled as to maintaining proper bowel habits, with antiplatlet therapy (Plavix), or anticoagulated with
such as the avoidance of straining and limiting prolonged warfarin (Coumadin) or heparin products. In general, the
DISEASES OF THE COLON & RECTUM VOLUME 54: 9 (2011) 1061

performance of a banding procedure is contraindicated in approach in the operating room. One should avoid lanc-
this group because the exceedingly high incidence of post- ing techniques with simple incision and drainage, be-
procedure bleeding. cause they tend to result in higher rates of reaccumula-
tion and may worsen symptoms with further expansion
Sclerotherapy. Sclerotherapy involves injection of 3 to 5 of the thrombosis.
mL of a sclerosant into the apex of an internal hemorrhoid. 6. Surgical hemorrhoidectomy should be reserved
This relatively simple procedure may be used for small, for patients who are refractory to office procedures,
bleeding internal hemorrhoids with success rates reported who are unable to tolerate office procedures, who have
in 75% to 89% of patients with grades I to III disease.21,22 large external hemorrhoids, or who have combined in-
Unfortunately, longer follow-up intervals often demon- ternal and external hemorrhoids with significant pro-
strate a relatively higher rate of symptomatic recur- lapse (grades III to IV). Grade of Recommendation:
rence.2327 This approach may be particularly appealing in Strong recommendation based on moderate-quality
those with bleeding tendencies, such as the patient receiv- evidence 1B
ing antiplatlet or anticoagulation therapy. Complications
are uncommon; the most frequent one is minor discom- Surgical Excision. Surgical excision of hemorrhoids re-
fort or bleeding with injection. Rare, serious complications mains a very effective approach. In general, it should be
have resulted from erroneous injection site placement or reserved for patients for whom office-based procedures fail
systemic effects of the solution itself, including the creation or who cannot tolerate these procedures, grade III or IV
of rectourethral fistulas, rectal perforations, and necrotiz- hemorrhoids, or patients with substantial external skin
ing fasciitis.24,28 33 These compilations have been de- tags. In a meta-analysis of 18 randomized prospective
scribed in isolation or in conjunction with the simultane- studies comparing hemorrhoidectomy with office-based
ous application of rubber bands.24,27 procedures, hemorrhoidectomy was the most effective
treatment for patients with grade III hemorrhoids. How-
Infrared Coagulation. Infrared coagulation involves the ever, it was associated with increased pain and the highest
direct application of infrared waves that results in protein complication rate.13
necrosis within the hemorrhoid. This is most commonly Either open or closed hemorrhoidectomy can be per-
used for grade I and II hemorrhoids. Although previous formed with a variety of surgical devices including surgical
reports have demonstrated high rates of recurrence, espe- scalpel, scissors, monopolar cauterization, bipolar energy,
cially with grades III and IV,34 recent randomized stud- and ultrasonic devices.41 43 In general, there appears to be
ies have demonstrated outcomes similar to rubber band no definitive advantage of one over the other.44,45 As such,
ligation.35,36 individual patient factors and preferences need to be care-
fully weighed and considered before a decision for opera-
Complications. Overall, the incidence of major complica- tive therapy. In a recent meta-analysis of 12 studies with
tions is rare; yet, one must remember that perianal sepsis 1142 patients, the use of a bipolar energy device was found
has been described as a life-threatening complication with to be faster and to provide less postoperative pain in com-
all office-based procedures. The onset of urinary retention parison with conventional hemorrhoidectomy.46 Addi-
and fever immediately after an office-based procedure may tional studies particularly addressing increased cost during
be the initial sign of perianal sepsis and mandates emergent surgery are needed to further define the relative place of
patient evaluation. As such, patients should be counseled each of these modalities for operative intervention.
regarding these rare but devastating complications with all
office-based hemorrhoid procedures, and patients should Hemorrhoidopexy. Stapled hemorrhoidopexy uses a cir-
be counseled appropriately.32,37,38 cular stapling device that resects internal hemorrhoids and
5. Most patients with thrombosed external hemor- fixes the remaining tissues in place. Although effective for
rhoids benefit from surgical excision within 72 hours internal prolapsing disease, it may not adequately address
of the onset of symptoms. Grade of Recommendation: external hemorrhoids. A recent meta-analysis comparing
Strong recommendation based on low-quality evi- stapled hemorrhoidopexy with conventional excisional
dence 1C hemorrhoidectomy demonstrated a higher long-term re-
Although most patients treated conservatively will ex- currence rate in patients undergoing stapled hemorrhoid-
perience eventual resolution of their symptoms, excision opexy.47
of thrombosed external hemorrhoids results in more rapid Early cohort and smaller nonrandomized trials re-
symptom resolution, lower incidence of recurrence, and ported stapled hemorrhoidopexy to be associated with less
longer remission intervals.39,40 Most excisions can be pain and faster recovery in comparison with conventional
safely performed in the office setting, although extensive hemorrhoidectomy. An early meta-analysis including
large thrombosed hemorrhoids and those extending 1077 patients came to similar conclusions.47 However, a
into the anal canal may require a more formal surgical more recent Cochrane review of 6 randomized trials with
1062 RIVADENEIRA ET AL: PRACTICE PARAMETERS FOR HEMORRHOIDS

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