Version July 2025
INTRODUCTION —
Most symptomatic hemorrhoids are first treated conservatively with dietary or lifestyle changes and medications. Office-based procedures (eg, rubber band ligation) are then offered to those with persistent symptoms, while surgery is reserved for those who do not respond to office treatments or cannot tolerate them.
This topic will review common surgical techniques used to treat hemorrhoids. The anatomy and clinical features of hemorrhoids, and nonsurgical treatment options, are discussed separately. (See "Hemorrhoids: Clinical manifestations and diagnosis" and "Home and office treatment of symptomatic hemorrhoids".)
PREOPERATIVE PREPARATION
●Anticoagulants and antiplatelet agents – Medications that increase the risk of bleeding (eg, warfarin, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs) should be preferably held in the perioperative period depending on the urgency for treatment and risk of cessation. Perioperative management of anticoagulation is discussed separately. (See "Perioperative medication management", section on 'Medications affecting hemostasis' and "Perioperative management of patients receiving anticoagulants".)
●Bowel preparation – The patient usually undergoes a cleansing enema before the procedure. A full mechanical bowel preparation is not indicated and may be counterproductive.
●Prophylactic antibiotics – Based on limited data, prophylactic antibiotics are not beneficial before routine, elective hemorrhoid procedures, as the risk of infection is low [1,2]. Patients with underlying immunosuppression or extensive cellulitis may benefit from perioperative antibiotics (table 1).
PATIENT POSITIONING —
Either a prone, lithotomy, or lateral position can be used to perform hemorrhoid procedures as determined by surgeon preference and hemorrhoid location.
●Prone – Many colorectal surgeons prefer the prone jackknife position due to the superior view and exposure to the perianal region it affords. However, patients requiring airway control must first be intubated on the transport stretcher before being positioned prone on the operating room table.
●Lithotomy or lateral – For patients unable to tolerate the prone position because of concerns with airway control, the lithotomy or left-lateral positions are acceptable alternatives. However, visualization and access to the base of the hemorrhoid may be more difficult.
In all cases, it is important to prevent undue pressure on the pelvis and genitalia and to pad all bony prominences, paying special attention to the legs when the lithotomy position is used. (See "Nerve injury associated with pelvic surgery", section on 'Avoid prolonged lithotomy position'.)
ANESTHESIA —
Hemorrhoid surgery can be performed under general, regional (spinal, epidural), or local anesthesia with or without conscious sedation [3-10]. Local anesthesia with intravenous sedation yields the best post-hemorrhoidectomy pain relief [11,12]. Surgeon preference guides the choice, although patient body habitus, airway, or respiratory status also matter.
Perianal blocks — Local anesthetic is typically administered in the perianal region during hemorrhoidectomy, except for patients undergoing spinal anesthesia. This infiltration significantly alleviates pain, whether used alone or in conjunction with other anesthesia methods [13].
The types of perianal blocks include anal block, pudendal nerve block, ischiorectal block, posterior perineal block, and local wound infiltration [14]. Among these, anal block is the most common.
During an anal block, local anesthetic, often with epinephrine, is injected into the ischiorectal fat surrounding the external sphincter [15]. Sodium bicarbonate (1 cc per 30 cc lidocaine) may be added to minimize local irritation if the patient remains awake.
Longer-acting local anesthetics (eg, ropivacaine, bupivacaine, or liposomal bupivacaine) provide greater decrease in post-hemorrhoidectomy pain compared with short-acting agents (eg, lidocaine) [16,17] (table 2). The addition of triamcinolone to local anesthetics can reduce postoperative pain and narcotic requirements [18].
EXTERNAL HEMORRHOIDECTOMY —
External hemorrhoids generally do not require surgical management. Exceptions may include:
●Thrombosed external hemorrhoids.
●Large external hemorrhoids or skin tags that cause symptoms (eg, pain) or interfere with hygiene.
●External hemorrhoids combined with internal hemorrhoids (ie, mixed hemorrhoids) that cause symptoms (eg, bleeding).
Thrombosed external hemorrhoids — Patients with a thrombosed external hemorrhoid present with an acutely painful purplish or blue mass in the perianal area (picture 1 and picture 2).
Nonoperative management — When the patient presents over three days after symptom onset, usually with symptoms already improving, surgery is not required [19]. After 48 to 72 hours, the thrombus organizes and contracts, lessening symptoms.
Occasionally, a thrombosed hemorrhoid will evacuate spontaneously, leaving a small ulcer with residual clot at the anal opening (picture 3). This will typically resolve on its own over a few weeks, leaving only a skin tag.
Excision — For patients who present in severe pain (typically within three days after symptoms onset) or significant bleeding, surgical intervention can provide immediate relief [20,21].
When surgery is needed, we suggest excision of the thrombosed hemorrhoid, rather than incision and evacuation of the clot [22,23]. However, if excision is not feasible, incising the hemorrhoid to remove the clot can also alleviate pain. (See 'Enucleation' below.)
Excision of the thrombosed external hemorrhoids has been shown to prevent recurrent thrombosis. The recurrence rate for a completely excised thrombosed hemorrhoid is 5 to 19 percent [22,23]. By comparison, simple incision and evacuation of the clot is associated with a 30 percent risk of reaccumulation and thrombosis, which may spread to adjacent hemorrhoidal columns [24].
Excision of external hemorrhoids can be performed in the operating room, emergency room, or an appropriately equipped office in the following steps:
●The skin covering the hemorrhoid is prepped with povidone-iodine solution, and local anesthetic is injected around the base and into the overlying area. The authors also supplement this with an anal block for better analgesia. (See 'Perianal blocks' above.)
●An elliptical incision is made in the skin overlying the thrombosed hemorrhoid with a scalpel, scissors, or electrocautery pen (figure 1).
●The incision is carried around the hemorrhoid and dissected with care from the superficial fibers of the anal sphincter, making certain to avoid injury. The thrombosis and the resultant edematous tissue create a readily identifiable plane for dissection.
●The skin edges can be left open and allowed to drain or reapproximated with absorbable sutures, depending upon surgeon preference [25]. Following application of a topic antibiotic ointment, the wound is covered by a dressing to protect clothing from soilage. (See 'Postoperative care and follow-up' below.)
Patients with extensive thrombosis (picture 4) have a higher risk of injury if the perianal skin and anoderm are aggressively resected. The key to surgery in such patients is to remove the hemorrhoid while sparing the anoderm and allowing time for the inflammation to subside. Such patients are better treated in the operating room rather than the bedside. Multiple elliptical incisions can be used to limit excision of anoderm and perianal skin.
Enucleation — For clinicians who do not feel comfortable excising a thrombosed external hemorrhoid, an alternative, though not preferred, is to simply incise the overlying skin to evacuate thrombus from the hemorrhoid, which can produce immediate relief of pain.
When incision is used instead of excision for hemorrhoids, a residual clot may occur if the incision is too small, leading to potential reaccumulation of blood and thrombosis. Thus, patients should be seen by a surgeon within 24 to 48 hours.
Symptomatic external or mixed hemorrhoids — Symptomatic external or mixed external-internal hemorrhoids that are not thrombosed can only be removed. For these patients, excisional hemorrhoidectomy is required. (See 'Choosing a surgical treatment' below.)
INTERNAL HEMORRHOIDECTOMY —
Because they lack sensory nerve innervation, internal hemorrhoids can be treated with one of several office-based procedures that do not require anesthesia (see "Home and office treatment of symptomatic hemorrhoids", section on 'Techniques'). Surgical treatment is only required in one of the following situations:
●Prolapsed internal hemorrhoids that require manual reduction (grade III) or are incarcerated (grade IV) (picture 2).
●Symptomatic internal hemorrhoids (eg, pain, bleeding) refractory to or intolerant of office-based procedures (See "Home and office treatment of symptomatic hemorrhoids", section on 'Office-based procedures for symptomatic hemorrhoids'.)
Choosing a surgical treatment — There are three types of surgical treatments for hemorrhoids:
●Excisional hemorrhoidectomy excises the hemorrhoidal tissue with a scalpel, monopolar electrocautery (conventional hemorrhoidectomy), or other advanced electrosurgical devices (eg, LigaSure hemorrhoidectomy, Harmonic hemorrhoidectomy).
●Stapled hemorrhoidopexy excises hemorrhoidal and redundant anal mucosal tissues with a circular stapler. The 2024 guidelines from the American Society of Colorectal Surgery did not recommend stapled hemorrhoidopexy as a first-line surgical treatment for internal hemorrhoids due to its marginal efficacy and significant risk profile [24].
●Hemorrhoidal arterial ligation (HAL) does not excise any tissue but ligates arteries that feed the hemorrhoids with ultrasound-guided precision. A mucopexy can be added to treat prolapse.
Excisional hemorrhoidectomy can be used to treat both internal and external hemorrhoids. Stapled hemorrhoidopexy and HAL do not address external hemorrhoids. Thus, patients with external or combined internal and external hemorrhoids can only be treated with excisional hemorrhoidectomy.
A 2015 systematic review and network meta-analysis of 98 randomized trials compared clinical outcomes and effectiveness of various hemorrhoidectomy techniques used to treat grade III and IV internal hemorrhoids [26]. Results indicate that (table 3):
●Excisional hemorrhoidectomy using conventional instruments leads to the most postoperative pain and complications, resulting in extended hospital stays and recovery times. However, it's also linked to the lowest recurrence rate.
●Compared with excisional hemorrhoidectomy performed with conventional instruments, LigaSure or Harmonic hemorrhoidectomy reduces operation time, blood loss, postoperative complications, and pain. (See 'Conventional instruments versus advanced energy devices' below.)
●Stapled hemorrhoidopexy has shorter operating times and less postoperative pain than excisional hemorrhoidectomy, allowing for a quicker return to normal activities and shorter hospital stays. However, its recurrence rate is higher than conventional excisional hemorrhoidectomy or LigaSure procedures. Stapled hemorrhoidopexy also carries more postoperative complications than Harmonic hemorrhoidectomy and a higher postoperative bleeding rate than HAL. (See 'Stapled hemorrhoidopexy' below.)
●In the short term, HAL offers the most favorable outcomes among all procedures, with reduced operative and recovery time, decreased postoperative pain, bleeding, and complications, as well as fewer emergency reoperations. However, HAL also has the highest recurrence rate among all procedures. (See 'HAL' below.)
Other randomized trials or meta-analyses of randomized trials that compared stapled hemorrhoidopexy versus excisional hemorrhoidectomy [27-30], HAL versus excisional hemorrhoidectomy [31-34], or HAL versus stapled hemorrhoidopexy [35,36] reached similar conclusions. Minor discrepancies arise from variations in excisional hemorrhoidectomy techniques, with some meta-analyses combining studies using both conventional and advanced instruments. (See 'Conventional instruments versus advanced energy devices' below.)
Surgeons may limit their offering of hemorrhoid procedures due to differences in expertise and available equipment [24]. When multiple options are available, the decision should be guided by the patient's values and preferences. While excisional hemorrhoidectomy typically provides more lasting outcomes, stapled hemorrhoidopexy or HAL may be preferred by patients seeking to minimize postoperative pain and downtime.
Excisional hemorrhoidectomy — The goals of an excisional hemorrhoidectomy are to remove the redundant tissue, avoid damage to the sphincter, and avoid taking too much anoderm, which might lead to anal stenosis.
When performing hemorrhoidectomy, all three hemorrhoidal columns are usually treated simultaneously. For those less experienced in performing a three-column hemorrhoidectomy or in patients with concern that this would result in anal stenosis, one- or two-column hemorrhoidectomy may be performed [37].
Steps of excisional hemorrhoidectomy — Over the years, these basic steps of excisional hemorrhoidectomy remained the same, but technical details such as whether to close the mucosal defect or whether to use cold instruments or an energy source have evolved and diverged. (See 'Open versus closed hemorrhoidectomy' below and 'Conventional instruments versus advanced energy devices' below.)
●The junction of the internal and external component of the hemorrhoid is grasped with a small clamp (eg, Allis, Babcock) to retract the hemorrhoid away from the sphincter muscles.
●Using a scalpel or electrocautery pen, the rectal mucosa is scored in an elliptical or diamond shape around the hemorrhoidal bundle to delineate the plane for excision of the hemorrhoid.
●The incision is carried deeper starting distally on the external hemorrhoidal tissue and extending proximally across the dentate line to the superior most extent of the hemorrhoidal column.
●The hemorrhoid tissue is carefully dissected from the superficial internal and external sphincter muscles toward the main vascular pedicle in the anal canal. The base of the pedicle is suture ligated, and the hemorrhoidal tissue is removed.
●The mucosal defect is then left open to heal by secondary intention or closed with a continuous 2-0 or 3-0 absorbable suture (eg, Vicryl). (See 'Open versus closed hemorrhoidectomy' below.)
●Care must be taken not to narrow the anal canal when multiple hemorrhoidal excisions are performed. Only the redundant anoderm associated with the hemorrhoidal tissue should be removed, preserving a minimum of 1 cm of anoderm between columns. A Hill-Ferguson retractor should be left in place until all suturing is complete.
●Evidence suggests that lateral sphincterotomy or injection of botulinum toxin into internal anal sphincter (IAS) [38-41] can prevent IAS spasm and thus reduce postoperative pain after hemorrhoidectomy [42]. However, lateral sphincterotomy should not be routinely used due to the risk of incontinence. Only patients who have internal hemorrhoids that are associated with a high resting IAS pressure or concomitant fissure disease may benefit from supplemental sphincterotomy. (See "Anal fissure: Surgical management".)
Open versus closed hemorrhoidectomy — The two main types of excisional hemorrhoidectomy are the closed (Ferguson) hemorrhoidectomy and the open (Milligan-Morgan) hemorrhoidectomy (excision and ligation without mucosal closure).
●Closed hemorrhoidectomy, or a modification of the technique, is the more commonly performed procedure for internal hemorrhoidectomy. This technique is successful in 95 percent of cases and has a low rate of wound infection [37]. The authors prefer a closed approach.
●Open hemorrhoidectomy is preferred for acute gangrenous hemorrhoids where tissue edema and necrosis prevent closure of the mucosa without undue tension [43]. In most other clinical settings, the handling of the mucosal wound is left to the discretion of the surgeon.
There is no definitive advantage between open and closed hemorrhoidectomy. Closed hemorrhoidectomy, according to a meta-analysis of 11 trials involving 1326 patients, led to less postoperative pain, faster wound healing, and reduced bleeding [44]. However, more patient-important outcomes such as complications and recurrences were similar. Thus, the choice between open or closed hemorrhoidectomy is at the discretion of the surgeon [45].
Conventional instruments versus advanced energy devices — A variety of devices, including surgical scalpels, scissors, or electrosurgical devices (eg, monopolar electrocautery, advanced bipolar sealing [LigaSure], ultrasonic desiccation [Harmonic scalpel], laser), can be used to make the incision and excise the hemorrhoidal tissue. (See "Overview of electrosurgery".)
Meta-analyses of mostly randomized trials reported that compared with cold surgical instruments and monopolar electrocautery, advanced energy devices resulted in shorter operating times and less postoperative pain [46-48]. There is no significant difference between various advanced energy devices [49]. However, these devices can be costly and there is no variance in longer-term patient-important outcomes. Thus, resource permitting, excisional hemorrhoidectomy can be performed with any instruments that the surgeon prefers. (See 'Choosing a surgical treatment' above.)
Stapled hemorrhoidopexy — Stapled hemorrhoidopexy is an alternative to excisional hemorrhoidectomy for internal hemorrhoids only. The technique uses a circular stapling device to excise a circumferential column of mucosa and submucosa from the upper anal canal, which reduces the hemorrhoidal tissue back into the anal canal and fixates them into position [50]. The device also interrupts part of the hemorrhoidal blood supply, thereby decreasing vascularity [51-53]. The need for a specialized device makes this procedure more expensive [54-57].
Steps of stapled hemorrhoidopexy
●An anal dilator and obturator provided with the surgical stapler is first inserted into the anus to dilate the anal canal (figure 2).
●The most critical component of the procedure is the placement of the pursestring suture in the mucosa/submucosa approximately 4 cm from the dentate line. It is important that the pursestring suture be placed far enough proximal to avoid involving the sphincter muscles within the stapling device and to minimize other complications (eg, changes in continence, stricture, fistula).
●The circular stapling device is introduced into the anus, and the pursestring suture is tied to gather the mucosa/submucosa contents into the stapler.
●Before the stapler is engaged or fired, the posterior wall of the vagina should be assessed to ensure the stapler has not inadvertently engaged it. This can be noted by moving the stapler and seeing that the posterior vaginal wall does not tent or move with it.
●When the stapler is fired, it creates a circular fixation of all tissues within the nonabsorbable circumferential pursestring suture to the rectal wall. In effect, it will draw up and suspend the prolapsed internal hemorrhoid tissue.
●The staple line should be fully evaluated and any bleeders should be suture ligated. The staple line is a source for early postoperative bleeding.
●Postprocedural tenesmus and reoperations are more prevalent among patients who undergo stapled hemorrhoidopexy [29]. One study suggested that defecatory symptoms may respond rapidly and completely to oral nifedipine [58].
Additionally, several unique and potentially serious complications have been associated with stapled hemorrhoidopexy [59]. These include rectal perforation, rectovaginal fistula, staple line bleeding, or stricture. Such complications are not commonly seen with excisional hemorrhoidectomy.
HAL — Another alternative to excisional hemorrhoidectomy is Doppler-guided transanal HAL, also known as total hemorrhoidal dearterialization [60-64]. HAL uses a specially designed proctoscope housing a Doppler transducer to identify and ligate each hemorrhoidal arterial blood supply. A mucopexy procedure is added for patients with symptomatic prolapse.
Like stapled hemorrhoidopexy, HAL can only treat internal hemorrhoids. HAL does not excise any tissue; thus, it may have a role where excision is contraindicated (eg, patients on anticoagulation) [65].
Steps of HAL
●The specialized proctoscope is inserted and rotated so that the built-in Doppler probe can be used to identify the six trunks of hemorrhoidal arteries first proximally in the rectum, then followed distally to the apex of the internal hemorrhoids [66]. The spots are marked.
●If only dearterialization is required (ie, the patient has bleeding but no tissue prolapse), each artery is individually ligated with a Z-stitch.
●For patients with prolapse, a running stitch is started higher up and ensured to incorporate a Z-stitch above and below the marked spot with the strongest Doppler signal, thus accomplishing both dearterialization and mucopexy.
●The mucopexy suture ends just proximal to the apex of the internal hemorrhoid. Adequate distance should be reserved laterally between mucopexy sutures to avoid impeding venous return.
HAL versus rubber band ligation — In a randomized trial of 337 patients with symptomatic grade II or III internal hemorrhoids, HAL is more effective but more painful and costly compared with a single rubber band ligation [67]. For patients with symptomatic grade II or III internal hemorrhoids, a course of rubber band ligation remains the first-line procedure of choice due to its low morbidity and cost. Patients who fail, refuse, or cannot tolerate rubber band ligation should be referred for one of the surgical hemorrhoidectomy procedures. (See 'Choosing a surgical treatment' above.)
Rubber band ligation of internal hemorrhoids is discussed in detail in another topic. (See "Home and office treatment of symptomatic hemorrhoids", section on 'Rubber band ligation'.)
POSTOPERATIVE CARE AND FOLLOW-UP —
In the initial days after hemorrhoid surgery, patients often experience considerable pain and swelling. Supportive care typically involves warm sitz baths, stool softeners, and pain medications such as acetaminophen, anti-inflammatory drugs, or oral narcotics. The wound often opens after three to five days, with possible mucus drainage from the area. However, symptoms like high fever (>101°F), significant erythema or necrosis, or persistent pain should prompt further evaluation as they could indicate complications. (See 'Complications' below.)
Pain management — Pain following hemorrhoid surgery is nearly universal and may in part be due to spasms of the internal sphincter. Perianal anesthetic infiltration with long-acting agents at the time of surgery is important for reducing postoperative pain. (See 'Perianal blocks' above.)
Initial pharmacologic treatment to control postoperative pain consists of topical analgesics (eg, topical lidocaine) and oral analgesics, such as nonsteroidal anti-inflammatory drugs and/or acetaminophen [13]. Opioids may be given if pain is not well controlled but carry the potential adverse effects of inducing constipation and possibly worsening the pain. (See "Approach to the management of acute pain in adults".)
Other options to manage pain have been evaluated in randomized trials and meta-analyses:
●Topical calcium channel blocker (eg, diltiazem) [68] or nitroglycerin [69] has been shown to reduce post-hemorrhoidectomy pain. The mechanism of benefit is presumably related to relaxation of the internal anal sphincter (IAS).
●Topical metronidazole (10%) has also been shown to decrease postoperative pain following hemorrhoidectomy as well as decrease post-defecation discomfort [70]. Oral metronidazole has also been shown to be beneficial for pain control [71], although the data are still mixed [72].
●Several other topical agents, including EMLA, aloe vera, and sucralfate, have been evaluated, but the results are inconclusive [73].
Warm sitz bath — A sensation of "tightness" after the procedure can usually be alleviated with a warm sitz bath that can be performed as often as needed by the patient. Physiologic studies showed that anal resting pressure diminished significantly after a warm sitz bath (40°C) for 5 to 10 minutes [74]. The effects of warm water on the relaxation of the IAS could last up to 70 minutes after exiting the bath [75]. Of note, simple warm water is all that is required, and the addition of other bath or Epsom salts is not necessary.
Avoiding constipation — A bulk fiber supplement and/or increased dietary fiber and fluid intake will help reduce postoperative constipation and pain upon defecation. Fecal impaction after a hemorrhoidectomy is associated with postoperative pain and opiate use. Most surgeons recommend stimulant laxatives, stool softeners, and bulk fiber to prevent this problem. Should impaction develop, manual disimpaction under anesthesia may be required.
COMPLICATIONS —
The incidence of complications following hemorrhoidectomy is low overall. The nature of complications depends upon the type and extent of procedure.
●Following excision of a thrombosed external hemorrhoid, minor bleeding (<1 percent) and local swelling are common, and perianal abscess/fistula can also occur (approximately 2 percent). The most common complication is recurrent hemorrhoids that require another procedure (approximately 6 percent). Internal sphincter injury occurs infrequently (<1 percent) but has undesirable consequences [23].
●Following excision of internal hemorrhoids, the most common complications are bleeding and urinary retention [50]. Rare complications are rectal perforation and sepsis, rectovaginal fistula, minor changes in continence, and retroperitoneal and pelvic abscess [76].
Major complications following hemorrhoid surgery include urinary retention, urinary tract infection, fecal impaction, and delayed hemorrhage. Proper technique and adequate postoperative care can help prevent some of these complications. Other complications include sphincter damage (which is rare) and wound dehiscence (which is common but usually of no clinical consequence).
Urinary retention — Urinary retention following hemorrhoidectomy is observed in as many as 30 percent of patients [77]. Spinal anesthesia tends to be associated with higher rates of urinary retention [3]. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study) [78]. Warm sitz baths and pain medication also may lessen the incidence of urinary retention and reduce the need for catheterization. Some patients will require urinary catheterization, although some remain relatively asymptomatic. (See "Acute urinary retention", section on 'Bladder decompression'.)
Urinary tract infection — Urinary tract infection develops in approximately 5 percent of patients after anorectal surgery [79], possibly secondary to occult urinary retention. (See "Catheter-associated urinary tract infection in adults".)
Bleeding — Delayed hemorrhage, probably due to sloughing of the primary clot, develops in 1 to 2 percent of patients; it usually occurs 7 to 16 days postoperatively [79]. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for suture ligation.
Disturbance of bowel continence — In most cases, minor alterations in continence may be noted in the first few weeks following hemorrhoidectomy due to pain, anal spasm, and changes in sensation (ie, discriminating between liquid, solid stool, and gas). These patients typically get better with time, though bulking agents may help.
Fecal incontinence can occur in approximately 2 to 10 percent of patients [80,81]. Management of fecal incontinence, including medical therapy and injectable materials, is reviewed separately. (See "Fecal incontinence in adults: Management".)
Anal stricture — Anal stricture formation occurs in approximately 1 percent of patients and for internal hemorrhoidectomy is related to multiple-column hemorrhoidectomies where too much anoderm has been resected.
Infectious complications (rare) — Surgical site infection is uncommon after hemorrhoid surgery; however, submucosal abscess (<1 percent) and deep space infection can occur, although severe fasciitis or necrotizing infections are rare [76,79].
SOCIETY GUIDELINE LINKS —
Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Hemorrhoids".)
INFORMATION FOR PATIENTS —
UpToDate offers two types of patient education materials, "The Basics" and "Beyond the Basics." The Basics patient education pieces are written in plain language, at the 5th to 6th grade reading level, and they answer the four or five key questions a patient might have about a given condition. These articles are best for patients who want a general overview and who prefer short, easy-to-read materials. Beyond the Basics patient education pieces are longer, more sophisticated, and more detailed. These articles are written at the 10th to 12th grade reading level and are best for patients who want in-depth information and are comfortable with some medical jargon.
Here are the patient education articles that are relevant to this topic. We encourage you to print or e-mail these topics to your patients. (You can also locate patient education articles on a variety of subjects by searching on "patient info" and the keyword(s) of interest.)
●Basics topics (see "Patient education: Hemorrhoids (The Basics)")
●Beyond the Basics topics (see "Patient education: Hemorrhoids (Beyond the Basics)")
SUMMARY AND RECOMMENDATIONS
●Treatment of hemorrhoids – Most symptomatic hemorrhoids are first treated conservatively with dietary or lifestyle changes and medications. Office-based procedures (eg, rubber band ligation) are then offered to those with persistent symptoms, while surgery is reserved for those who do not respond to office treatments or cannot tolerate them. (See 'Introduction' above and "Home and office treatment of symptomatic hemorrhoids".)
●External hemorrhoids – When patients present with a thrombosed external hemorrhoid over three days after symptom onset, usually with symptoms already improving, surgery is not required. After 48 to 72 hours, the thrombus organizes and contracts, lessening symptoms.
For patients who present in severe pain (typically within three days after symptom onset) or significant bleeding, surgical intervention can provide immediate relief. For these patients, we suggest hemorrhoid excision rather than incision and evacuation of the clot (Grade 2C). Simple incision and evacuation of the clot is associated with a higher recurrence rate. (See 'External hemorrhoidectomy' above and 'Thrombosed external hemorrhoids' above.)
Nonthrombosed, symptomatic (eg, pain, bleeding) external hemorrhoids or mixed external-internal hemorrhoids can only be treated with excisional hemorrhoidectomy. (See 'Symptomatic external or mixed hemorrhoids' above.)
●Internal hemorrhoids – There are three mainstream surgical treatments of internal hemorrhoids:
•Excisional hemorrhoidectomy excises the hemorrhoidal tissue with a scalpel, monopolar electrocautery, or other advanced electrosurgical devices (eg, LigaSure, Harmonic scalpel). The wound can be closed (Ferguson) or left open (Milligan-Morgan). (See 'Excisional hemorrhoidectomy' above.)
•Stapled hemorrhoidopexy excises hemorrhoidal and redundant anal mucosal tissues with a circular staple. (See 'Stapled hemorrhoidopexy' above.)
•Hemorrhoidal arterial ligation (HAL) does not excise any tissue but ligates arteries that feed the hemorrhoids with Doppler-guided precision. (See 'HAL' above.)
The choice should be made based on available resources, surgeon preference, and the patient's values and preferences. While excisional hemorrhoidectomy typically provides more lasting outcomes, stapled hemorrhoidopexy or HAL may be preferred by patients seeking to minimize postoperative pain and downtime. (See 'Choosing a surgical treatment' above.)
●Postoperative care – Following hemorrhoid surgery, the anal area is covered by a dressing to protect clothing. The wounds will generally heal within a couple of weeks. Pain is expected and can be controlled primarily using acetaminophen/nonsteroidal anti-inflammatory agents and warm sitz baths. Narcotic medications can be used if needed, but these may cause constipation. Patients are instructed to avoid constipation. (See 'Postoperative care and follow-up' above.)
●Complications – The incidence of complications following hemorrhoidectomy is low overall. The main complications following a conventional hemorrhoidectomy technique include urinary retention, urinary tract infection, fecal impaction, and delayed hemorrhage. (See 'Complications' above.)
