Haemorrhoids

Definition — cushions that slip, a sphincter that grips

Haemorrhoids are engorgement and prolapse of the anal cushion driven by two paired mechanisms — weakening of the cushion's support and spasm of the internal sphincter — with bowel habits and lifestyle as the modifiable risk factors.^[3] The symptom set is bleeding, pain, prolapsing, swelling, itching and mucus soiling, and the first triage is anatomical: internal disease above the dentate line bleeds painlessly and prolapses, while external disease below it hurts only when thrombosed.^[3][4][9]

Hold the AGA pain rule as an absolute: haemorrhoids only cause significant pain when acutely thrombosed, and sharp pain on defecation is most likely anal fissure.^[4] That single sentence separates three referrals — the painless bleeder for banding, the acute tender lump for excision-or-wait, and the sharp-defecation-pain patient for fissure care — and getting it wrong means banding a fissure or excising internal disease through sensitive skin.^[4][9]

Classification — Goligher for trials, BPRST for the patient in front of you

Goligher grades prolapse in four steps — I (bleed, no prolapse), II (spontaneous reduction), III (manual reduction), IV (irreducible) — and every guideline uses it to choose treatment: banding up to grade III, ligation-excision for grades III-IV, haemorrhoidectomy for grade 4 and for grade 3 that fails banding or carries external disease.^[3][4] It is also the most widely used classification in practice, which is exactly why its weakness matters.^[5]

The weakness is measured: 95 Dutch surgeons, fellows and residents grading 25 photographs reached only fair overall agreement (Fleiss kappa 0.376) — moderate for grades I (0.466) and IV (0.522), fair for the middle grades II (0.206) and III (0.378) — even though 87% use it routinely and 81% find it helpful.^[5] Grades II and III are therefore where two examiners most often disagree, and where the operation chosen on grade alone is least reproducible.^[5]

BPRST (bleeding, prolapse, reduction, skin tags, thrombosis) was built for that gap. In the São Paulo prospective cohort of 229 patients, Goligher split disease 29/61/85/26 across grades I-IV while BPRST staged it 23/95/83 across stages I-III — and six Goligher-grade-I patients were reclassified BPRST stage III and required conventional excision for thrombosis (four patients) or intolerable tags (two), with BPRST tracking the operation chosen more closely and with fewer outliers than Goligher (p under 0.001).^[6] The viva position follows: keep Goligher as the trial language, but record reducibility, thrombosis and tags beside it — Goligher-blind grade I disease with thrombosis still needs excision.^[6]

Epidemiology and risk — common, straining-driven, fixable at the toilet

Prevalence estimates span 4 to 55% of the population depending on definition — the range itself tells you haemorrhoids are under-reported and over-assumed in roughly equal measure.^[3] The Nigerian endoscopy cohort of 121 cases grounds the bedside picture: bleeding per rectum the commonest presentation, predilection in decreasing order right posterior (34.1%), right anterior (28.2%), left lateral (17.1%) and left posterior (7.6%), with multiple quadrants involved in 72.5% of external disease and grades I/II/III seen in 31%, 26% and 17% of cases.^[7] In North America the burden is counted at 1 to 10 million affected, with nutrition, inherited predisposition, faecal retention and laxative or diarrhoeal abuse behind symptomatic disease.^[11]

The root-cause story the examiner rewards is mechanical: three deranged defecation habits — increased straining, prolonged defecation time, frequent motions — develop new haemorrhoids, progress existing ones and rupture them into bleeding.^[12] Correction has a mnemonic, TONE: three minutes at defecation, once-a-day frequency, no straining, enough fibre — implemented as 5 to 6 teaspoonfuls of psyllium husk with 600 mL of water daily plus counselling.^[12] Tested in 102 referred grade-III/IV patients (41 early-III, 38 late-III, 6 grade-IV), bleeding episodes fell from 71.8% to 29.4% (P under 0.0001), prolapse improved in 56.5% with no progression in a further 25.9%, 68.2% were highly satisfied — and only 12.9% ultimately underwent operation.^[12] Fibre plus no-strain toileting is therefore not folksy advice but the reasonable first-line therapy of the AGA guidance, with sitz baths often advised on thin evidence.^[4]

Presentation — the painless bleeder, the prolapse, and the transfusion trap

Internal haemorrhoids typically present with prolapse or painless rectal bleeding; external haemorrhoids also bleed and cause acute pain when thrombosed.^[9] Most patients have only mild symptoms manageable with nonprescription topicals plus stool softeners, and seek care when symptoms escalate — which is why the first visit must grade, not just soothe.^[9][10]

Respect the transfusion trap: among 520 surgical haemorrhoidectomy patients, 80.6% reported bleeding and 7.3% had haemorrhoidal bleeding requiring transfusion — major haemorrhoidal haemorrhage is under-reported, not rare.^[80] Anticoagulant or non-aspirin antiplatelet use independently predicted transfusion (odds ratio 3.08), and transfused patients endured heavy workups — colonoscopy in 94.7%, upper endoscopy in half, capsule endoscopy in over a quarter — so recognising the haemorrhoidal source early means expeditious surgical treatment instead of another costly scope.^[80]

Differential — never attribute bleeding to haemorrhoids without the workup

Haemorrhoids lead the causes of bright-red bleeding but never own it. The alarm-features meta-analysis of 31 studies and 45,100 patients (cancer prevalence 0.2 to 22%) found rectal bleeding only 49% sensitive and 69.8% specific for colorectal cancer — with bleeding and anaemia the only practical solo triggers for colonoscopy (numbers needed to scope 5.3 and 6.7 respectively).^[77] Weight loss (12.4% sensitive) never rules out cancer alone, and specificity peaks at 91.9% for weight loss precisely because it is uncommon.^[77]

The minimal-bleed study is the viva trap: 402 average-risk outpatients with small bright-red bleeds and no alarm features underwent colonoscopy — haemorrhoids led at 54.2%, but significant lesions hit 30.1%, including adenocarcinoma in 6.5% and adenomas in 7.5%, nearly all distal — so flexible sigmoidoscopy at minimum, not reassurance, is the floor.^[78] Tedesco's 1978 classic set the precedent: 304 patients with negative proctosigmoidoscopy and barium, of whom 258 bled — colonoscopy found significant lesions in 41.5% of bleeders including carcinoma in 11.2%, with lesions proximal to the splenic flexure — which is why bleeding with a negative limited examination still earns full colonic evaluation.^[79] And the young-adult cautionary case reminds you why: a 34-year-old whose spotty painless bleeding was attributed to internal haemorrhoids for three years presented anaemic and proved to have stage IV-B rectal adenocarcinoma — rectal bleeding is the commonest presentation sign in young-adult colorectal cancer, which runs aggressive and late.^[82]

In the Bosnian lower-bleed series of 603 colonoscopies, haemorrhoids were found in 42% yet combined pathologies in 95 cases — with haemorrhoids, diverticular disease and colorectal cancers together the commonest bleeding causes — so complete colonoscopy is advocated to catch proximal lesions even when haemorrhoids are staring at you.^[81]

Assessment — history, examination, anoscopy, grade

The AGA bedside script is short: history plus examination makes the diagnosis and grade easily, and anoscopy should be performed whenever possible on every new suspected-haemorrhoid patient before treatment to secure the diagnosis.^[4] Japanese doctrine agrees — thorough history plus anorectal examination, then Goligher to choose treatment.^[3] Grade at the bedside and record reducibility, thrombosis and tags alongside Goligher so the BPRST modifiers survive into the plan.^[6]

Use the same examination to exclude the mimics: fissure, prolapse, active inflammatory bowel disease, skin tags — and in cirrhotics, distinguish haemorrhoids from rectal varices before any band goes on, because the varix is not banded like a haemorrhoid.^[4][75] In pregnancy the assessment stays selective: history, examination and proctoscopy, with further imaging only in selected cases.^[74]

Two international guidelines frame the ladder used throughout this topic: the ASCRS 2024 clinical practice guideline for haemorrhoid management and the European Society of ColoProctology 2020 international multidisciplinary guideline, whose six sections (symptoms, diagnosis and classification; basic treatment; outpatient procedures; surgical interventions; special situations; other surgical techniques) carry 34 recommendations decided from the literature using GRADE.^[1][2]

Conservative and medical therapy — fibre first, flavonoids second, steroids brief

Start every grade with the base: fibre plus no-strain toileting as reasonable first-line therapy.^[4] The 1986 outpatient doctrine still holds for the mild majority — dietary change, stool softeners and local hydrocortisone creams manage most haemorrhoids conservatively, with persistently bleeding or painful internal disease stepping up to band ligation.^[10] Four degrees of prolapsed internal haemorrhoids remain the main indication for excision — high or low ligation with excision, closed Ferguson or stapler technique — while thrombosed external disease is primarily incised and secondarily excised, with operative complications for external thrombosis rare.^[11]

Flavonoids earn a qualified second line. In 162 colonoscopy-cleared patients with bleeding nonprolapsed haemorrhoids, micronised purified flavonoid fraction plus ispaghula stopped bleeding fastest (3.9 days) against banding plus ispaghula (5.6) and ispaghula alone (10.6), P = 0.03 — with no six-month recurrence separation.^[13] The flavonoid systematic review (11 studies across 13 articles) reported benefit across bleeding, pain, pruritus, discharge, tenesmus and overall improvement, with four-study pooling giving bleeding odds ratio 0.082, discharge 0.12, and patient-rated improvement 5.25.^[14] Cochrane phlebotonics (24 trials considered; 20 versus control in 2,344 participants) found the same direction — bleeding odds ratio 0.12, pruritus 0.23, discharge 0.12, post-haemorrhoidectomy bleeding 0.18, overall improvement 15.99 — with no significant pain signal and acknowledged methodological limits calling for stronger trials.^[15]

Topicals stay honest and brief: anaesthetics, astringents such as witch hazel, corticosteroids and vasoactives may be considered, but supportive data are thin — and topical steroids must not run beyond two weeks at a time.^[4] Tribenoside plus lidocaine (5%/2% cream; 400 mg/40 mg suppository) has the women-specific data: formally evaluated including in women, safe postpartum and in pregnancy after the first trimester, significantly improving subjective and objective symptoms in pregnancy with relief from 10 minutes lasting 10 to 12 hours — a defensible first-line topical when conservative therapy is indicated.^[16]

Office procedures — banding first, coagulation and sclerotherapy beside it

The office hierarchy is settled: banding or infrared coagulation before excision for grades 1 to 3, with banding holding the longer-term advantage for prolapse and recurrent bleeding.^[4] The twin 1990s meta-analyses of 18 trials each both recommend banding as the initial therapy for grades 1 to 3 — excision responds better but with more pain and complications, banding beats sclerotherapy for response overall (p = 0.005) and by grade (grades 1-2 p = 0.007, grade 3 p = 0.042) with equal complications, while sclerotherapy and coagulation both need more re-treatment than banding.^[17][18] The Cochrane banding-versus-excision review (three poor-quality trials, 202 patients) concurs on the trade: complete remission favours excision (relative risk 1.68) but with marked heterogeneity (I-squared 90.5%) — durable versus tolerable, not better versus worse.^[19]

Head-to-head numbers sharpen consent. Polidocanol foam versus banding in 120 grade I-III patients at one year: therapeutic success 93.3% versus 85.0% (not significant), with higher complete success on foam.^[23] Banding versus coagulation across nine trials: no difference in efficacy, prolapse, recurrence or retention — banding more painful, coagulation more bloody.^[20] Infrared coagulation versus banding in 100 second-degree bleeders: week-one pain stronger with banding (visual-analogue 2 to 5 versus 0 to 3) with more defecation pain and tenesmus (P = 0.0059), but coagulation patients returned to duties sooner (2 versus 4 days, P = 0.03).^[21] Walker 1990 (200 patients): coagulation beat injection-or-banding at three months for nonprolapsing disease (81% versus 59% symptom-free), yet prolapse recurred more after coagulation than banding at one year (54% versus 27%), with coagulation far less painful (P under 0.001) — rapid relief from prolapse belongs to the band.^[22]

Modern banding variants extend, not replace, the standard. Endoscopic banding of haemorrhoid-only versus combined haemorrhoid-plus-mucosa tissue (70 patients): 67.8% complete plus 27.4% partial resolution at 12 months with no efficacy gap — but combined ligation hurt more (postoperative pain 74.2% versus 45.2%).^[24] Modified banding beat Milligan-Morgan for pain, bleeding and urinary retention in 120 grade-III patients with resting anal pressure unchanged — against pressure rises after excision.^[25] Retroflexed multi-band ligation (82 patients, mean eight bands, 76 single-session) improved bleeding, prolapse and pain scores at four weeks.^[26] Laser haemorrhoidoplasty versus banding in 70 grade-II patients: less pain, bleeding and distension within two weeks on laser (P under 0.01), identical one-year recurrence, faster return to activity on laser.^[28] And the long view of endoscopic ligation (759 patients, mean 55.4 months): bleeding controlled in 98.0%, prolapse reduced in 82.5%, satisfaction 93.6% — with bleeding recurring in 3.7%, 6.6% and 13.0% at one, two and five years, and prolapse in 3.0%, 9.6% and 16.9%.^[27]

Dearterialization — HAL and THD with the HubBLe verdict

Dearterialization ligates the terminal superior-rectal branches under Doppler with mucopexy lifting the prolapse — sphincter-sparing, minimally invasive, and honestly positioned between office therapy and excision.^[30][31][32] The thousand-patient THD series (grades 2 to 4) reported 1.4% acute postoperative bleeding, pain or tenesmus in 3.1%, retention in 2.3% — with 9.5% symptomatic recurrence at a mean 44 months (bleeding 1.2%, prolapse 4.6%, both 3.7%), rising by grade (8.5%, 8.7%, 18.1% for grades 2, 3, 4) and 7.0% reoperated.^[30] The Brazilian 705-patient THD-mucopexy series across five centres reported 1.1% intraoperative complications with tenesmus in 21.4%, pain in 7.2% and prolapse in 6.4%.^[31] The minimal-open-versus-dearterialization trial exists precisely because long-term comparative evidence is thin — benign disease judges itself on symptom resolution and quality of life, enrolling grades II to IV.^[32]

HubBLe is the verdict to quote: 372 grade II-III patients across 17 UK trusts randomised to Doppler HAL or banding — one-year recurrence 30% after HAL versus 49% after banding (adjusted odds ratio 2.23, P = 0.0005) — but the gap was extra procedures to cure: single-HAL versus multiple-banding recurrence was 37.5% in the banding arm (adjusted odds ratio 1.35, not significant).^[35][36] Symptoms deteriorated in both arms between six weeks (persistent symptoms 9% HAL, 29% banding) and one year, with no symptom-score, quality-of-life, incontinence, pain or cost-effectiveness separation.^[36] The critical review draws the inference: dearterialization was promoted as non-excisional and less invasive, but HubBLe questions its overall place in management.^[8]

Price it further before offering it. The 408-patient HAL-plus-rectoanal-repair series carried 29% overall complications, 26% short-term prolapse persistence and 21% recurrent bleeding — settling long-term to 24% prolapse, 3% bleeding and 20% mixed symptoms — concluding relief for bleeding, itch and pain but not for prolapse-predominant disease.^[40] Excision beats dearterialization for durability (six-trial meta, 465 patients: recurrence odds ratio 2.76 with dearterialization, with faster return to baseline the consolation).^[33] Dearterialization also recurs more than stapling (six trials, 554 patients: 13.2% versus 6.9%, odds ratio 1.93) with similar complications, readmission, stay, return-to-work and satisfaction.^[34] Grade IV specifically: HAL with rectoanal repair in 100 consecutive grade-IV patients gave 9% recurrence at a mean 34 months with 84 same-day discharges — feasible, but uncontrolled against excision or stapling, which the authors concede.^[41] Device choice within dearterialization or stapling arms of the LigaLongo trial (193 dearterialization, 184 stapled across two device brands each) did not define outcome — technique selection matters more than the badge on the handle.^[42]

And the Doppler itself adds nothing: blind versus Doppler-guided ligation-repair across five studies showed no operative-time or bleeding difference with more urinary retention on Doppler (P under 0.001).^[37] The Russian 120-patient randomised comparison of ligation with versus without Doppler navigation (60 per arm) found no advantage for guidance in prolapse (P = 0.74), bleeding (P = 0.71), pain, complications or relapses.^[38] The seven-trial Doppler-usefulness review of 514 patients asks the same question — routine guidance is ritual, not evidence.^[39] Laser dearterialization (HeLP) resolves or improves symptoms in 83.6 to 100% short-to-medium term with 90% versus 53.3% against banding in its sole randomised comparison — on low-certainty evidence with long-term data still wanted.^[43]

Excisional surgery — the durable standard, refined by devices and closure

Conventional Milligan-Morgan, Ferguson and Ligasure excisions hold grade III-IV disease with the lowest recurrence at the price of pain — the standing summary of the evidence.^[8] Excision is one of the commonest operations for third- and fourth-degree prolapse, and with proper indication the standard operation is safe.^[51][11]

Closure matters: eleven randomised trials with 1,326 patients give closed (Ferguson) excision less postoperative pain (standardised mean difference minus 0.36), faster healing (odds ratio 0.08), less bleeding (odds ratio 0.50) — at the cost of longer operating time (standardised mean difference 6.10) — with defecation pain, stay, complications, recurrence and site infection similar.^[49] Energy devices compress the operation further: Ligasure and Harmonic scalpel versus diathermy in 180 patients cut median operating time from 18 to 8 minutes with lower week-one pain and fewer first-day analgesic ampoules and no complication difference.^[45] Bipolar diathermy versus ultrasonic scalpel for closed excision in 60 patients cut blood loss (0.9 versus 4.6 mL) and time (16 versus 31 minutes).^[46] Head-to-head, Ligasure beat Harmonic scalpel in 49 randomised grade 3-4 patients — pain scores 2.6 versus 4.8, analgesic tablets 5 versus 13, time 11 versus 18 minutes — with stay, satisfaction, pethidine use, bowel timing and complications similar.^[44] The Ligasure-versus-conventional meta-analysis agrees: equal cure, shorter time, less pain, faster healing and earlier return (all P under 0.001), no bleeding difference.^[47] The three-way 90-patient comparison (Ligasure, Harmonic, conventional) found no difference in stay, bleeding, incontinence, wetness, retention, stenosis, recurrence, pain scores, analgesia or quality of life — with pain tracking the number of bundles excised, and more lateral thermal damage under Ligasure microscopy.^[48] The harmonic-versus-bipolar meta-analysis frames the same contest as intra- and postoperative morbidity reduction.^[51] The 26-study network of 3,137 grade 3-4 operations across 14 techniques ranks laser, coagulation and stapling less painful than open or closed excision.^[50]

Two combined-strategy signals deserve viva mention. Standardised Ligasure excision for complex grade-III disease with large or circumferential prolapse (316 patients, Iraq): 28-minute mean operating time, severe pain 6.9%, retention 17.1% (higher with spinal than general anaesthesia), no bleeding, infection, stenosis or incontinence seen, one-day median stay, seven-day recovery, zero reoperations at one year with 11.8% minor bleeding.^[52] Milligan-Morgan plus non-Doppler artery ligation versus Milligan-Morgan alone in 115 grade III-IV patients (53 versus 62): lower pain scores through day seven in the combined arm.^[53]

Stapled haemorrhoidopexy — faster recovery, higher recurrence, real harms

Stapling trades durability for recovery — quote it in three eras. Twelve early trials: conventional excision prevents long-term recurrence (odds ratio 3.85) and prolapse (odds ratio 2.96), including beyond one year.^[54] Fifteen articles with 1,201 patients at one year or more: prolapse recurrence odds ratio 5.5 with stapling, re-treatment odds ratio 1.9.^[55] Seventeen randomised trials with 2,072 patients (trial-sequential analysis still underpowered at 1,913 of 2,608): overall recurrence risk ratio 1.56 with stapling, prolapse recurrence 3.28, bleeding recurrence no different at 1.20, with no reintervention, pain, function or quality-of-life separation.^[56]

The decade cohorts make it concrete. Ten-year stapled follow-up (86 grade-3 patients): 39% recurrent prolapse with eight reoperated, 44% urge to defecate, 8% gas leakage, 68% satisfied.^[57] Fifteen-year follow-up (257 operated, 140 traced): 47.4% any symptom recurrence, over half of it beyond ten years, with 15.2% needing re-intervention.^[58] Twelve-year survey (194 identified, 171 answering): 40.9% anatomical prolapse recurrence yet 75.6% improved, 56.7% any complication with 8.7% serious, tenesmus 38.2%, impaired continence 39.1%, 40.3% still needing occasional medical therapy, 9.3% reoperated — and still 81.2% rating satisfaction 3 or more out of 5.^[59]

The Italian 1,107-patient stapled audit prices the consent form: 15% complications — severe pain 5.0%, bleeding 4.2% (a quarter surgical, 6% transfused), thrombosis 2.3%, retention 1.5%, dehiscence 0.5% including one pelvic drainage with colostomy — then stenosis 0.8% and late recurrence 2.3%.^[60] Counsel pelvic-sepsis rarity before every haemorrhoid therapy, however office-based, with emergency re-presentation advice — the AGA makes this part of informed consent, not an afterthought.^[4]

Thrombosed external haemorrhoids — excise early or treat and watch honestly

Greenspon's 231 consecutive patients (1990-2002, mean 7.6-month follow-up to seven years) give the natural history: 51.5% conservative, 48.5% surgical, with prior thrombosis in 44.5% and pain-or-bleeding presentations selecting surgery.^[67] Symptoms resolved in 24 days conservative versus 3.9 days surgical; recurrence struck 25.4% conservative versus 6.3% surgical at 7.1 versus 25 months — excision resolves faster, recurs less and remits longer, while most conservative cases still resolve and no baseline variable predicted the right choice except prior history (likely patient preference).^[67]

Timing rules the choice: duration discriminates medical from surgical treatment, with surgery — radial-incision drainage, conventional excision, excision under local anaesthesia or stapled technique — recommended when conservative care fails or onset falls within the last 48 to 72 hours; special conditions such as pregnancy and elderly age adjust the call — and no specific thrombosis guideline exists to overrule judgement.^[68] The evidence base is admittedly thin: among 800 screened articles only two prospective (248 patients) and two retrospective (571) studies qualified — excision beats incision or topical nitrates by day four (level IB), conservative symptoms exceed three weeks (level III) shortened by adding nifedipine to lignocaine (level IB), with no evidence on optimal conservative timing.^[69] The six-study, 851-patient comparison adds that surgery halves recurrence (relative risk 0.49) without changing bleeding (relative risk 0.96).^[70]

The elderly series (87 patients over 75): remission in 11.8 days conservative versus 1.6 incision versus 7.8 excision, recurrence 19.4% versus 16.1% versus zero — bleeding commonest after incision-evacuation, major complications absent, excision the durable choice when accepted though often refused through fear.^[72] In pregnancy (53 patients: 26 conservative, 22 surgical with eight thrombectomies versus fourteen excisions): both arms improved, but surgery won physical and mental quality-of-life and grading scores by day ten with pain separating by day three — and excision beat thrombectomy so clearly (re-thrombosis 38% versus 7%) that randomisation halted on ethics, with no maternal or fetal complications in either arm.^[71]

Special populations — pregnancy, cirrhosis, immunocompromise, IBD

Pregnancy concentrates proctological disease in 45 to 68% from uterine pressure, volume expansion and pelvic venous stasis, with anal pain and constipation (over 60% constipated) dominant.^[74] Dublin's prospective cohort (258 patients: 184 antenatal with 82 affected at 45%, plus 74 postnatal) timed onset 15% first trimester, 30% second, 55% third — with 64% self-diagnosing without professional guidance, 45% resolving within days, and fibre, fluids and bath salts relieving most.^[73] AGA doctrine follows: fibre, constipation care and topicals first; banding or coagulation deferred until postpartum or between pregnancies.^[74] Perianal thrombosis in pregnancy — often misdiagnosed as thrombosed external haemorrhoids — peaks in the third trimester or just after delivery and usually yields to conservative pain control, with excision reserved for selected nodules.^[74]

In cirrhosis (incidence 21 to 79%, matching the general population), first distinguish haemorrhoids from anorectal varices — then treat: six studies (one randomised, two prospective, one retrospective, two series) across banding and sclerotherapy (aluminium-potassium-sulfate-tannic-acid, ethanolamine, cyanoacrylate) appear effective and safe, challenging old fears of office-procedure bleeding — while each patient's haemostatic balance and anaesthetic risk still individualise the call, and foam sclerotherapy needs randomised testing here.^[75] AGA adds the actionable thresholds: banding or coagulation is acceptable in cirrhosis, preferring coagulation when platelets fall below 50,000 per microlitre or INR exceeds 2.0, with portal hypertension changing nothing.^[4] In medication-immunosuppressed patients (Mayo: 55 patients, 68 procedures, rheumatoid arthritis and transplant leading) most societies still advise conservative-first for presumed sepsis and healing risk — know the caution even as the Mayo data suggest office and operative procedures can be safe and viable.^[76] And in active Crohn disease or ulcerative colitis, defer haemorrhoid management until complete remission.^[4]

Investigational edges — embolization and sclerobanding, framed as bridges

Superior-rectal-artery embolization ("emborrhoid") is a catheter-based bridge for grade I-III disease when office therapy fails or surgery is undesirable: 22 studies with 810 procedures give technical success 93 to 100%, clinical success 63 to 94%, recurrence needing re-treatment 8 to 20% (usually persistent collaterals), satisfaction above 80% throughout, mild self-limited complications only — but small single-centre cohorts, disparate techniques and only two small heterogeneous comparisons against banding or sclerotherapy, with no pooled analysis possible.^[66] The prospective 80-patient microcoil series (grades I 13.7%, II 71.1%, III 15%) reached 100% technical success with 68.7% bleed-free at 12 months, quality-of-life gains, 31.3% recurrent bleeding, 21.3% second embolizations, 5% conversions to open surgery and no major complications.^[65] Offer it, if at all, to frail or anticoagulated patients with informed consent about recurrence — multicentre randomised data with two-year follow-up are still required.^[66] Endoscopic polidocanol-foam sclerobanding (mucosal lift plus submucosal scarring to cut pain, bleeding and prolapse recurrence) is at the multicentre randomised stage against banding in grades II-III with one-year follow-up — novel, not standard.^[29] Newer walk-in-walk-out ablations (radiofrequency, laser) likewise await proper evaluation before entering the algorithm.^[8]

Consent, continence, satisfaction — and the closing viva line

Consent continence with the Ferguson numbers: 514 closed excisions followed a mean 4.7 years — soiling absent in 71.7%, light in 21.2%, moderate in 6.1%, severe in 0.98%, with 0.8% reoperated for recurrence and 91.9% rating excellent or good.^[61] Temper with physiology: liquid-continence testing in 76 Milligan-Morgan patients (2.4 masses excised; grades III 51.3%, IV 48.7%) was mixed — retained volume better in 40, worse in 27, same in nine — cushions contribute to continence, and function needs following, not assuming.^[62] Stapled long-term continence impairment reached 39.1% in the twelve-year survey — part of the stapling price alongside tenesmus.^[59] Satisfaction generally survives these trade-offs: 93.6% after endoscopic ligation, 91.9% excellent-or-good after Ferguson excision, 81.2% satisfied after twelve-year stapling — while tailored surgery (362 patients: 215 stapled, 99 excised, 48 combined) found no complication, recurrence or incontinence separation with better self-assessed quality-of-life gain in combined procedures.^{[27][61][59][63]} Laser haemorrhoidoplasty's five-year audit (50 grade II-III patients) counsels caution the other way: 98% short-term stage reduction and 92% improved at 60 days, but 18% complications including two fistulas and one incontinence, with 34% recurrence at a mean 5.4 years.^[64]

The closing viva line writes itself: banding first for grades 1 to 3, excision for grade 4 and failed grade 3, stapling for faster recovery at triple the prolapse recurrence — with HubBLe favouring HAL over single-course banding only until repeat banding is counted, Doppler guidance adding nothing, flavonoids helping bleeding but not pain, and every bleed worked up before it is ever called haemorrhoidal.^{[17][4][56][36][37][15][77]}

Revision summary

Cushion weakening plus sphincter spasm; internal painless bleeders versus thrombosed-external pain; Goligher for trials (kappa 0.376) with BPRST modifiers; fibre-TONE first line; banding first for grades 1-3 with 98% bleed control and 93.6% satisfaction; HubBLe 30% versus 49% with the multiple-banding caveat; closed beats open for pain, healing and bleeding; stapling recurs (prolapse risk ratio 3.28) across three eras; thrombosed disease excised within 72 hours or watched honestly (24 versus 3.9 days; 25.4% versus 6.3% recurrence); pregnancy conservative-first; cirrhosis band-or-coagulate after excluding varices; embolization investigational; and no bleed ever attributed without the alarm workup.^{[3][5][12][27][36][49][56][67][74][75][66][77]}

Transfused bleeders carried heavy workups — colonoscopy 94.7%, upper endoscopy 50% and capsule 26.3%.^[11] Symptoms shifted between 6 weeks and 1 year in the banding-versus-HAL arms without separation on symptoms, quality of life, incontinence, pain or cost-effectiveness.^[46]

societies treat duration as the discriminant — operate within 48-72 hours of onset (drainage by radial incision, conventional excision, excision under local, or stapled technique) and favour conservative care beyond it (flavonoids, lidocaine-nifedipine, botulinum toxin, 0.2% GTN, wait-and-see), with pregnancy and elderly cases weighed individually — and admit no specific EHT guideline exists (PMID 35592120).^[60]

only two prospective (248 patients) plus two retrospective (571) studies found among 800 screened — excision beats incision/GTN by day 4 (level IB), conservative symptoms exceed 3 weeks (level III) shortened by adding nifedipine to lignocaine (level IB), with no evidence on optimal conservative timing (PMID 23079956); the 6-study/851-patient SRMA adds surgery halves recurrence (RR 0.49) without changing bleeding (RR 0.96) (PMID 40576944); in over-75s (n=87) remission took 11.8 days conservative versus 1.58 incision versus 7.8 excision, recurrence 19.4% versus 16.1% versus 0%, with bleeding commonest after incision — excision the durable choice when accepted (PMID 30600960).^[69]

References82ShowHide

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