Surgical treatment of hemorrhoidal disease

INTRODUCTION — Hemorrhoids are normal vascular structures in the anal canal. Approximately 5 percent of the general population is affected by symptoms related to hemorrhoidal disease [1]. The cardinal features of hemorrhoidal disease include bleeding, anal pruritus, prolapse, extra tissue causing difficulty with hygiene, and pain due to thrombosis. Although these symptoms may strongly suggest the diagnosis, confirmation by flexible sigmoidoscopy, anoscopy, or colonoscopy should be performed in most patients who present with bleeding, especially those deemed at higher risk for malignancy or additional symptoms (ie, weight loss, changes in bowel habits) and those who are not up to date on screening recommendations [2].

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".)

INDICATIONS — The initial approach to treating most patients with hemorrhoids is conservative. Patients who fail medical management may be candidates for a nonsurgical office-based procedure prior to requiring surgical treatment. Ongoing symptoms in spite of conservative or office-based treatment usually require surgical intervention. (See "Home and office treatment of symptomatic hemorrhoids", section on 'Conservative treatment for all patients'.)

Surgical excision of hemorrhoids remains a very effective approach for treatment of symptomatic hemorrhoids, but is reserved for select patients [3]. A formal hemorrhoidectomy in appropriately selected patients can resolve the patient's symptoms and minimize recurrent disease when performed properly. Patients with grade III or IV hemorrhoids, and those with severe external disease, appear to benefit the most from surgery. Patients who are unable to tolerate office-based procedures due to significant comorbidities or taking anticoagulation medication may also benefit from an excisional hemorrhoidectomy. Some patients may prefer surgical treatment sooner rather than later, after a frank discussion of other treatment options and the benefits and risks of surgery. (See "Home and office treatment of symptomatic hemorrhoids" and "Hemorrhoids: Clinical manifestations and diagnosis", section on 'Anatomy and Classification'.)

A surgical procedure is generally limited to those with the following clinical conditions [4]:

External hemorrhoids — (See 'External hemorrhoidectomy' below.)

●Symptomatic external hemorrhoids (eg, pain, thrombosis) refractory to conservative measures

●Symptomatic external hemorrhoids (eg, pain, thrombosis) refractory to office-based procedures, or unable to tolerate office-based procedures because of pain

●Large or severely symptomatic external hemorrhoids (eg, severe pain, interfere with hygiene, severe skin irritation and itching)*

●Patients with substantial external skin tags

●Combined internal and significant external hemorrhoids

●Symptomatic external hemorrhoids in the presence of a concomitant anorectal condition that requires surgery

*It is important to note that for some indications, failed prior treatment is not required prior to proceeding with surgical treatment.

Internal hemorrhoids — (See 'Internal hemorrhoidectomy' below.)

●Prolapsed internal hemorrhoids that can be manually reduced (Grade III), particularly if more than one column is involved*

●Prolapsed and incarcerated internal hemorrhoids (Grade IV)* (picture 1)

●Symptomatic internal hemorrhoids (eg, pain, thrombosis) refractory to conservative measures

●Symptomatic internal hemorrhoids (eg, pain, thrombosis) refractory to office-based procedures, or unable to tolerate office-based procedures because of pain*

●Combined internal and external hemorrhoids

●Symptomatic internal hemorrhoids in the presence of a concomitant anorectal condition that requires surgery

*It is important to note that for some indications, failed prior treatment is not required prior to proceeding with surgical treatment.

PREOPERATIVE EVALUATION AND PREPARATION — The preoperative assessment includes a detailed history; physical examination, which includes external inspection of the anus and a digital rectal examination; and anoscopy. Medications, particularly those that increase the risk of bleeding (eg, warfarin, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs [NSAIDs]), should be reviewed and are preferably held in the perioperative period depending on the indications for treatment and risk of cessation. Consultation with the patient's primary care provider or cardiologist may be warranted. Perioperative management of anticoagulation is discussed separately. (See "Perioperative medication management", section on 'Medications affecting hemostasis' and "Perioperative management of patients receiving anticoagulants".)

In most cases, the patient is instructed to undergo a cleansing enema before the procedure. A full mechanical bowel preparation is not indicated and may be counterproductive.

There is a paucity of data regarding the need for antibiotic prophylaxis. One retrospective study reported that there was no benefit to preoperative use of metronidazole compared with no antibiotics [5]. Another small randomized controlled trial found no difference in pain or infectious outcomes with the use of antibiotics for patients undergoing a Milligan-Morgan hemorrhoidectomy [6]. The authors agree that antibiotics are not necessary in most clinical settings, as the risk of infection is low. Patients with underlying immunosuppression or extensive cellulitis may benefit from perioperative antibiotics, such as metronidazole or a second-generation cephalosporin.

Immediately prior to performing the procedure, anoscopy should be repeated in the semi-inverted jackknife or left lateral position. The assessment includes an evaluation for the presence of external hemorrhoids, location, volume, redundancy, and grade of internal hemorrhoids. (See "Hemorrhoids: Clinical manifestations and diagnosis", section on 'Anatomy and Classification' and "Hemorrhoids: Clinical manifestations and diagnosis", section on 'Initial evaluation'.)

ANESTHESIA — Hemorrhoid surgery can be performed using general anesthesia, conscious sedation, regional anesthesia (spinal, epidural), perianal block, or straight local anesthesia [7-14]. The choice is often one of surgeon preference, but patient-related factors also play a role. One of the authors uses intravenous sedation and a perianal block for nearly all hemorrhoid surgeries. Occasionally, a regional (spinal) anesthetic or general anesthetic may be needed for selected patients, such as those with respiratory conditions (ie, cannot lay supine or prone, require airway protection).

The patient is first anesthetized (general, regional, intravenous) and positioned (see 'Positioning' below) for the procedure. An anal block is performed (see 'Perianal anesthesia/block' below), and a Hill-Ferguson retractor is placed into the anal canal and rectum to facilitate adequate inspection of the individual internal hemorrhoid columns.

Positioning — Patient positioning is another primarily surgeon-dependent variable. Although many anesthesia providers may be more comfortable with the lithotomy position, the authors prefer prone jackknife positioning for most cases as it provides an excellent view and exposure of the perianal region for the surgeon as well as for an assistant or trainee. The prone position can be used for patients who need their airway controlled. The patient is typically intubated on the transport stretcher first, then turned prone onto the operating room table. For these patients, it may be prudent to keep the patient's stretcher in the operating room in the event that the patient needs to be quickly returned to the supine position, though this is rarely necessary. 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, care should be taken to avoid unnecessary pressure on the male genitalia and to pad all bony prominences, particularly the legs when lithotomy position is used. (See "Nerve injury associated with pelvic surgery", section on 'Avoid prolonged lithotomy position'.)

Perianal anesthesia/block — Because of the frequency of postoperative pain, a perianal block is administered to most patients. In a systematic review that assessed analgesia following hemorrhoidectomy, perianal infiltration of local anesthetic provided significant pain relief, whether given alone or as a supplement to other forms of anesthesia [15]. In randomized trials, long-acting liposomal bupivacaine (eg, Exparel) was associated with a significantly greater decrease in post-hemorrhoidectomy pain compared with traditional bupivacaine [16] and decreased opioid use [17].

If spinal anesthesia is used, perianal anesthesia is not necessary. A formal pudendal nerve block has also been shown to reduce hemorrhoidectomy pain in a systematic review including 17 studies [18].

An anal block is performed by injecting local anesthetic (eg, lidocaine, bupivacaine), typically with epinephrine (table 1), into the ischiorectal fat immediately peripheral to the external sphincter [19]. Sodium bicarbonate (1 cc per 30 cc lidocaine) can be added per provider discretion to help minimize local irritation with injection if the patient remains awake. Additional data has suggested the addition of triamcinolone to local anesthesia can reduce postoperative pain and narcotic requirements [20].

EXTERNAL HEMORRHOIDECTOMY — External hemorrhoids generally do not require surgical management. Exceptions may include thrombosed external hemorrhoids or large external hemorrhoids that cause symptoms that cannot be controlled or interfere with hygiene. (See "Home and office treatment of symptomatic hemorrhoids", section on 'Conservative treatment for all patients' and 'Indications' above.)

Thrombosed external hemorrhoids — Patients with a thrombosed external hemorrhoid present with an acutely painful purplish or blue mass in the perianal area (picture 2 and picture 1). Some surgeons advocate excision of the thrombosed external hemorrhoids to prevent recurrent thrombosis. For those patients who present in persistent pain (typically within 72 hours from the onset), excision of the thrombosed external hemorrhoid provides immediate relief [21]. Conservative management only is recommended when the patient presents with diminishing symptoms (typically later than this 72 hour timeframe) [22]. After 48 to 72 hours, the thrombus organizes and contracts, lessening symptoms and obviating the need for surgical management. 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, although the patient may be left with a skin tag that rarely causes enough symptoms to warrant its removal. However, in those patients who have a skin tag large enough to cause skin irritation, itching, pain, or inability to keep proper hygiene, excision can be beneficial.

Techniques — When indicated, external thrombosed hemorrhoids are best treated with hemorrhoid excision, rather than incision and simple evacuation of the clot, an approach that should generally be avoided [23,24]. However, if timely evaluation by a surgeon is not available and the provider is not comfortable with excision of the thrombosed hemorrhoid, incision of the hemorrhoid can be performed to remove the clot, which should lessen symptoms. (See 'Excision' below and 'Incision' below.)

The recurrence rate for a completely excised thrombosed hemorrhoid is 5 to 19 percent [23,24]. By comparison, simple incision and evacuation of the clot is associated with a 30 percent risk of reaccumulation and thrombosis, which may disseminate to adjacent hemorrhoidal columns [22].

Excision — Excision of external hemorrhoids (thrombosed or symptomatic) can be performed in the operating room, emergency room, or an appropriately equipped office.

The skin overlying the hemorrhoid is prepped with povidone iodine solution, and local anesthesia is infiltrated into the skin at the base and overlying the area of excision around the hemorrhoid. A supplemental anal block, in addition to this infiltration, can also be performed and is preferred by the authors. (See 'Perianal anesthesia/block' above.)

●Excision of a thrombosed hemorrhoid (figure 1) is performed by making an elliptical incision in the skin overlying the hemorrhoid. The thrombosis and the resultant edematous tissue create a readily identifiable plane for dissection. The incision is carried around the hemorrhoid and dissected with care from the superficial fibers of the anal sphincter, making certain to avoid injury. Patients with extensive thrombosis (picture 4) have a higher risk of injury if the perianal skin and anoderm are aggressively resected. The excision can be performed with a scalpel, scissors, or electrocautery pen, depending on the preference of the surgeon. The skin edges can be left open and allowed to drain or reapproximated with absorbable sutures, also depending upon surgeon preference [25]. A topical antibiotic ointment can be applied to the wound; however, this is not necessary, as infection is rare in this well-vascularized site.

●Excision of a nonthrombosed hemorrhoid is performed in the same manner, simply making an elliptical incision around the skin and hemorrhoidal tissue (in the absence of a clot).

Following excision of an external hemorrhoid, the anal area is covered by a dressing to protect the clothing from soilage. (See 'Postoperative care and follow-up' below.)

Incision — For clinicians who do not feel comfortable excising the overlying skin of a thrombosed external hemorrhoid, an alternative is to simply incise the overlying skin. Evacuation of thrombus from the hemorrhoid can produce immediate relief of pain. However, clot evacuation is less likely to be beneficial if the patient is seen after 48 hours following the onset of pain. In general, the authors do not recommend this technique, as when hemorrhoid incision, rather than excision, is used, there can be residual clot if the incision is too small, and reaccumulation of blood and thrombosis can occur. Thus, follow-up within the next 24 to 48 hours for surgical evaluation is generally advised. (See 'Techniques' above.)

INTERNAL HEMORRHOIDECTOMY — Hemorrhoidectomy techniques differ predominantly based upon how the hemorrhoidal tissue is removed and whether or not the rectal mucosa is closed. Conventional hemorrhoidectomy excises the hemorrhoidal tissue with a scalpel, monopolar electrocautery, or other advanced electrosurgical devices (eg, Ligasure, Harmonic scalpel). Alternative methods of hemorrhoidectomy, such as stapling and hemorrhoidal artery ligation, have also been performed. (See 'Techniques' below.)

Choosing a hemorrhoidectomy technique — A 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 2):

●Conventional hemorrhoidectomy has the highest rate of postoperative complications but the lowest rate of recurrence.

●Hemorrhoidal artery ligation (HAL) has the lowest rate of postoperative complications but the highest rate of recurrence.

●Stapled hemorrhoidectomy has both a modest postoperative complication rate and a modest recurrence rate.

●Conventional hemorrhoidectomies performed with one of the advanced electrosurgical devices (eg, LigaSure or Harmonic scalpel) may cause less severe pain but cost more compared with the ones performed with a scalpel or monopolar electrocautery.

The ultimate choice of procedure, however, is determined by surgeon preference as individual surgeons may not have either the expertise or equipment required to perform all hemorrhoidectomy procedures [22].

Open versus closed hemorrhoidectomy — The two main types of conventional hemorrhoidectomy are the closed (Ferguson) hemorrhoidectomy and the open (Milligan-Morgan) hemorrhoidectomy (excision and ligation without mucosal closure). (See 'Techniques' below.)

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 [27]. Open hemorrhoidectomy is preferred for acute gangrenous hemorrhoids where tissue edema and necrosis prevent closure of the mucosa without undue tension [28]. In most other clinical settings, the handling of the mucosal wound is left to the discretion of the surgeon, though the authors prefer a closed approach. In general, there appears to be no definitive advantage between open or closed hemorrhoidectomy [27,29]. 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 [27].

One study compared open hemorrhoidectomy to a modified closed approach ("semi-open") in 300 patients [29]. The semi-open technique was associated with more rapid healing and a lower incidence of postoperative complications. In another trial, 40 patients undergoing open and 40 patients undergoing closed hemorrhoidectomy were compared, and the pain score at the first bowel movement was significantly lower for the closed group [30]. As might be expected, wound healing was significantly faster for the closed group (75 versus 18 percent at three weeks postoperatively). Nevertheless, in the absence of high-quality evidence, it remains up to the discretion of the surgeon as to which of these techniques is performed [31].

Conventional versus stapled — Conventional hemorrhoidectomy can be used to treat both internal and external hemorrhoids. Stapled hemorrhoidopexy does not address external hemorrhoids. Thus, in patients with external or combined internal and external hemorrhoids, conventional hemorrhoidectomy is preferred.

Both conventional hemorrhoidectomy and stapled hemorrhoidopexy are most commonly used to treat symptomatic prolapsing (grade II, III, and IV) internal hemorrhoids. A large randomized trial (eTHoS) permitted direct comparison of the two techniques [32]. Stapled hemorrhoidopexy resulted in less pain than conventional hemorrhoidectomy in the initial six weeks postsurgery. At 12 and 24 months, however, patients treated with stapled hemorrhoidopexy reported worse incontinence, tenesmus, and hemorrhoid symptoms; more hemorrhoid recurrences; and worse quality of life compared with those treated with conventional hemorrhoidectomy.

Earlier trials and systematic reviews agreed that stapled hemorrhoidopexy was less painful but that conventional surgery resulted in better symptom relief and fewer recurrences [33-36]. Additionally, postprocedural tenesmus and reoperations were more prevalent among patients who underwent stapled hemorrhoidopexy [35]. A 2019 meta-analysis also associated stapled hemorrhoidopexy with higher rates of complications and recurrences compared with open procedures [37].

Considering the evidence, we suggest choosing a hemorrhoidectomy procedure based on the patient's values and preferences. Overall, conventional hemorrhoidectomy appears to offer better and more durable outcomes than stapled hemorrhoidopexy. For patients who prefer to minimize pain and "downtime" after surgery, however, stapled hemorrhoidopexy remains a viable option.

Although more commonly reported for stapled hemorrhoidopexy than conventional hemorrhoidectomy, serious complications can occur with both procedures [36]. In the eTHoS trial cited above, serious adverse events, such as rectal bleeding, anal stenosis, and urinary retention, occurred in 9 and 7 percent of patients undergoing conventional and stapled hemorrhoid surgery, respectively [32]. (See 'Techniques' below.)

Stapled versus hemorrhoidal artery ligation — In a multicenter randomized trial of 393 patients with grade II or III internal hemorrhoids, hemorrhoidal artery ligation resulted in less postoperative pain (visual analogic scale 2.2 versus 2.8 postoperative; 1.3 versus 1.9 at two weeks) and a shorter sick leave (12 versus 15 days) but was more expensive (€2806 versus €2538), took longer to perform (44 versus 30 minutes), left more residual grade III disease (15 versus 5 percent), and required more reoperations (8 versus 4 percent). Otherwise, hemorrhoidal artery ligation and stapled hemorrhoidectomy had comparable complication (24 versus 26 percent) and patient satisfaction rates (>90 percent in both groups). It should be noted that neither stapled hemorrhoidectomy nor hemorrhoidal artery ligation is useful against grade IV hemorrhoids [38].

Techniques

Conventional — A variety of devices, including surgical scalpels, scissors, or electrosurgical devices (eg, monopolar electrocautery, advance bipolar sealing [Ligasure], ultrasonic desiccation [Harmonic scalpel], laser), can be used to make the incision and excise the hemorrhoidal tissue [39-42]. (See "Overview of electrosurgery".)

The goals of hemorrhoid resection are to remove the redundant tissue, avoid damage to the sphincter, and avoid taking too much anoderm, which might lead to anal stenosis. For conventional hemorrhoidectomy, 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 superiormost 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. 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.

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). To minimize the chance of narrowing the anal canal, a Hill-Ferguson retractor should be left in place until all suturing is complete. (See 'Open versus closed hemorrhoidectomy' above.)

Stapled — Stapled hemorrhoidopexy is an alternative to conventional internal hemorrhoidectomy. This procedure does not effectively treat most external hemorrhoids. The need for a specialized device makes this procedure more expensive [43-46]. 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 [47]. The device also interrupts part of the hemorrhoidal blood supply, thereby decreasing vascularity [48-50]. (See 'Techniques' above.)

An anal dilator or obturator is provided with the surgical stapler and provides gentle dilatation of the anal canal (figure 2). The circular stapling device is introduced into the anus, and the mucosa/submucosa contents are brought 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 purse string 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 as this is a potential source for early bleeding and may require a suture ligation. 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).

One role for stapled hemorrhoidopexy devices is to treat patients with bleeding and/or prolapsing grade II to IV internal hemorrhoids who have failed rubber band ligation. Another role may be for patients seeking a potentially less painful alternative to conventional surgery, but the patient must be willing to accept a higher risk of recurrence [51]. (See 'Conventional versus stapled' above.)

Occasional but important complications have been reported, including persistent post-defecation pain, which affects a small percentage of patients. One study suggested that such symptoms may respond rapidly and completely with oral nifedipine [52]. Although an option for patients with grade II to IV internal hemorrhoids, the stapled techniques, as stated above, will not address the external hemorrhoid component if present. Thus, in patients with combined internal and external hemorrhoids, the external hemorrhoids are surgically excised, obviating the benefit of using the stapling device.

Hemorrhoidal artery ligation — An alternative to a conventional hemorrhoidectomy or stapled hemorrhoidopexy is Doppler-guided transanal hemorrhoidal artery ligation (HAL), also known as transanal hemorrhoidal dearterialization (THD) [53-57]. HAL uses a specially designed proctoscope housing a Doppler transducer to identify each hemorrhoidal arterial blood supply, which is subsequently ligated.

A meta-analysis identified 28 observational studies involving 2904 patients undergoing Doppler-guided hemorrhoidectomy [58]. Recurrence rates ranged between 3 and 60 percent (pooled mean 17.5 percent), and the rate of postprocedure hemorrhage was 5 percent. A later randomized trial that included 40 patients with grade II or grade III hemorrhoids found that, although fecal soiling was decreased using both treatments, patients treated with HAL had significantly increased fecal soiling after one year compared with open hemorrhoidectomy [59]. Additional trials with longer-term observation are needed to determine the utility of this approach.

In a randomized trial of 337 patients with symptomatic grade II or III internal hemorrhoids, HAL resulted in fewer recurrences than rubber band ligation at 12 months (30 versus 49 percent) [60]. However, this difference was almost entirely accounted for by the need for repeat banding, which is a common practice but which was counted as recurrences in this study. Compared with rubber band ligation, HAL was associated with more pain at one and seven days after the procedure, more serious adverse events requiring hospitalization (7 versus 1 percent), and higher cost (£1750 versus £723).

Thus, HAL is more effective but more painful and costly compared with a single rubber band ligation. 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 hemorrhoidectomy technique' 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'.)

OTHER PROCEDURES

Supplemental sphincterotomy — Patients who have internal hemorrhoids that are associated with a high resting internal anal sphincter pressure may benefit from supplemental sphincterotomy. Sphincterotomy should generally be reserved for patients with concomitant fissure disease, and it should be avoided in those who have normal resting sphincter pressure [61]. (See "Anal fissure: Surgical management".)

POSTOPERATIVE CARE AND FOLLOW-UP — It is fairly common for patients to experience a fair amount of pain over the first few days, along with significant swelling. Postoperative instructions include warm sitz baths, stool softeners, and pain medication including oral narcotics and anti-inflammatory medications. Often, the wounds will open after three to five days, and patients may note mucus drainage from the area. High fevers (>101° F), significant expanding erythema or necrosis, or unremitting pain are all concerning and warrant further evaluation.

Pain management — Pain following hemorrhoidectomy is nearly universal and may in part be due to spasm of the internal sphincter. Perianal anesthetic infiltration at the time of hemorrhoidectomy is important for reducing postoperative pain. (See 'Perianal anesthesia/block' above.)

Initial pharmacologic treatment to control postoperative pain consists of oral analgesics, such as nonsteroidal anti-inflammatory drugs and/or acetaminophen [15]. 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 small randomized trials:

●A trial of 18 patients found that topical diltiazem ointment (2 percent) applied to the perianal region three times daily for seven days postoperatively was significantly more effective than placebo in reducing pain and the need for prescription narcotics [62]. The mechanism of benefit is presumably related to relaxation of the internal anal sphincter.

●Botulinum toxin injection compared with placebo has been associated with significant reductions in postoperative pain and the time of healing [63].

●Topical metronidazole (10%) has also been shown to decrease postoperative pain following hemorrhoidectomy as well as decrease post-defecation discomfort [64]. Oral metronidazole has also been shown to be beneficial for pain control [65], although the data are still mixed [66].

Local care — 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. 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 with anesthesia may be required.

COMPLICATIONS — The incidence of complications following hemorrhoidectomy is overall low. The main complications following a standard technique for hemorrhoidectomy include urinary retention, urinary tract infection, fecal impaction, and delayed hemorrhage. 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 [67,68]. Proper technique and adequate postoperative care can help prevent some of these complications. (See 'Techniques' above and 'Postoperative care and follow-up' above.)

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 [24]. (See 'Thrombosed external hemorrhoids' above.)

●Following excision of internal hemorrhoids, the most common complications are bleeding and urinary retention [47]. Rare complications are rectal perforation and sepsis, rectovaginal fistula, minor changes in continence, and retroperitoneal and pelvic abscess [67]. (See 'Internal hemorrhoidectomy' above.)

Urinary retention — Urinary retention following hemorrhoidectomy is observed in as many as 30 percent of patients [69]. Spinal anesthesia tends to be associated with higher rates of urinary retention [7]. Limiting postoperative fluids may reduce the need for catheterization (from 15 to less than 4 percent in one study) [70]. 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 [68], 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 [68]. No specific treatment is effective for preventing this complication, which usually requires a return to the operating room for suture ligation.

Fecal incontinence — Fecal incontinence can occur in approximately 2 to 10 percent of patients [71,72]. Management of fecal incontinence, including medical therapy and injectable materials, is reviewed separately. (See "Fecal incontinence in adults: Management".)

Other complications include sphincter damage (which is rare) and wound dehiscence (which is common but usually of no clinical consequence). 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.

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.

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 5^th to 6^th 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 10^th to 12^th 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 – Hemorrhoids are normal vascular structures in the anal canal. The initial approach to treating most patients with hemorrhoids is conservative. For patients who fail medical management or cannot tolerate an office-based procedure, surgical excision remains a very effective approach for treatment of symptomatic hemorrhoids. For some indications, failed prior treatment is not required prior to proceeding with surgical treatment. (See 'Introduction' above and 'Indications' above.)

●Preoperative preparation – Routine perioperative antibiotics are not necessary. A full mechanical bowel preparation is also not necessary, but patients are usually given an enema just prior to the procedure. Medications that increase the risk of perioperative bleeding (eg, warfarin, aspirin, clopidogrel, nonsteroidal anti-inflammatory drugs [NSAIDs]) should be reviewed and are preferably held in the perioperative period depending on the indications for treatment and risk of cessation. Consultation with the patient's primary care provider or cardiologist may be warranted. (See "Perioperative medication management", section on 'Medications affecting hemostasis'.)

●Patient positioning – Patient positioning is primarily determined by the surgeon. The authors prefer prone-jackknife positioning for most cases. 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. Care should be taken to avoid pressure points. (See 'Positioning' above.)

●Anesthesia and pain control – Hemorrhoid surgery can be performed using general anesthesia, regional anesthesia, or straight local anesthesia. The choice is often one of surgeon preference, but patient-related factors also play a role. For all hemorrhoid surgeries (external or internal hemorrhoidectomy, internal hemorrhoidopexy), we infiltrate local anesthetic in the perianal region at the time of hemorrhoidectomy, except in patients undergoing spinal anesthesia. Perianal infiltration of local anesthetic provides significant pain relief, whether given alone or as a supplement to other forms of anesthesia. (See 'Perianal anesthesia/block' above.)

●Excision of external hemorrhoids – External hemorrhoids generally do not generally require surgical management. When surgery is indicated for thrombosed external hemorrhoids, we suggest hemorrhoid excision rather than simple incision evacuation of the clot (Grade 2C). Simple incision and evacuation of the clot is associated with a high rate of recurrence. (See 'External hemorrhoidectomy' above and 'Thrombosed external hemorrhoids' above.)

●Excision of internal hemorrhoids – Internal hemorrhoidectomy techniques differ predominantly based upon how the hemorrhoidal tissue is removed and whether or not the rectal mucosa is closed.

•The two main types of conventional hemorrhoidectomy are the closed (Ferguson) hemorrhoidectomy and open (Milligan-Morgan) hemorrhoidectomy (excision and ligation without mucosal closure). In general, there appears to be no definitive advantage between open or closed hemorrhoidectomy, but closed hemorrhoidectomy (or a modification of the technique) is more commonly performed to treat internal hemorrhoids. All three internal hemorrhoidal columns are usually treated simultaneously. (See 'Internal hemorrhoidectomy' above.)

•Stapled hemorrhoidopexy is an alternative to conventional internal hemorrhoidectomy. It does not effectively treat external hemorrhoids. Stapled hemorrhoidectomy may have a role in patients with bleeding and/or prolapsing grade II to IV internal hemorrhoids who have failed rubber band ligation or for patients seeking a less painful alternative to conventional surgery but who are willing to accept a higher risk of recurrence. (See 'Stapled' above.)

•An alternative to a conventional hemorrhoidectomy or stapled hemorrhoidopexy is Doppler-guided transanal hemorrhoidal artery ligation (HAL). HAL is associated with the lowest rate of postoperative complications (including pain) but has the highest recurrence rate. (See 'Hemorrhoidal artery ligation' above.)

●Postoperative care – Following hemorrhoid surgery, the anal area is covered by a dressing to protect the clothing. Pain can be controlled primarily using 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. The wounds will generally heal within a couple of weeks. (See 'Postoperative care and follow-up' above.)

●Complications – The incidence of complications following hemorrhoidectomy is overall low. The main complications following a conventional hemorrhoidectomy technique include urinary retention, urinary tract infection, fecal impaction, and delayed hemorrhage. (See 'Complications' above.)