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48
3 Anal Cushions andPathophysiology ofHemorrhoids
References
1. Johanson JF, Sonnenberg A.The prevalence of hemorrhoids and chronic constipation. An epidemiologic
study. Gastroenterology. 1990;98(2):380–6.
2. Rogozina VA. Gemorroĭ [Hemorrhoids]. Eksp Klin
Gastroenterol. 2002;4:93–134.
3. Lawrence A, McLaren ER.External hemorrhoid. In:
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4. Thomson WH.The nature of hemorrhoids. Br J Surg.
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5. Alexander-Williams J, Crapp AR.Conservative management of hemorrhoids. Part I: injection, freezing,
and ligation. Clin Gastroenterol. 1975;4(3):595–618.
6. Lohsiriwat V. Treatment of hemorrhoids: a coloproctologist’s view. World J Gastroenterol.
2015;21(31):9245–52.
7. Lohsiriwat V.Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol.
2012;18(17):2009–17.
8. Yang HK. The pathophysiology of hemorrhoids. In:
Hemorrhoids. Berlin: Springer; 2014. p.15–24.
9. Zoulamoglou M, Kaklamanos I, Zarokosta M, etal.
The ligament of Parks as a key anatomical structure for safer hemorrhoidectomy: anatomic study
and a simple surgical note. Ann Med Surg (Lond).
2017;24:31–3.
10. Agarwal N, Singh K, Sheikh P, Mittal K, Mathai V,
Kumar A. Executive summary—the Association of
Colon & Rectal Surgeons of India (ACRSI) practice
guidelines for the management of hemorrhoids-2016.
Indian J Surg. 2017;79(1):58–61.
11. Blarucha AE, Wald A.Anorectal diseases. In: Yamada
T, editor. Textbook of gastroenterology. 5th ed. West
Sussex: Wiley-Blackwell; 2009. p.1717.
12. Agbo SP. Surgical management of hemorrhoids. J
Surg Tech Case Rep. 2011;3(2):68–75.
13. Smith M. Hemorrhoidectomy: past and present. Dis
Colon Rectum. 1961;4:442–4.
14. Pilcher JE.Guy de Chauliac and Henri de Mondeville.
A surgical retrospect. Ann Surg. 1895;21(1):84–102.
15. Aigner F, Gruber H, Conrad F, et al. Revised morphology and hemodynamics of the anorectal vascular
plexus: impact on the course of hemorrhoidal disease.
Int J Color Dis. 2009;24(1):105–13.
16. Soop M, Wolff BG. “Total” hemorrhoidectomy: the
whitehead hemorrhoidectomy and modications. In:
Khubchandani I, Paonessa N, Azimuddin K, editors.
Surgical treatment of hemorrhoids. London: Springer;
2009. p.95–100.
17. Margetis N.Pathophysiology of internal hemorrhoids.
Ann Gastroenterol. 2019;32(3):264–27.
18. Milligan ET, Morgan CN, Jones L, Ofcer R.Surgical
anatomy of the anal canal, and the operative treatment
of hemorrhoids. Lancet. 1937;230(5959):1119–24.
19. Aigner F, Bodner G, Gruber H, et al. The vascular nature of hemorrhoids. J Gastrointest Surg.
2006;10(7):1044–50.
20. Sun Z, Migaly J.Review of hemorrhoid disease: presentation and management. Clin Colon Rectal Surg.
2016;29(1):22–9.
21. Sharma M, Rai P, Bansal R.EUS-assisted evaluation
of rectal varices before banding. Gastroenterol Res
Pract. 2013;2013:619187.
22. Haas PA, Fox TA, Haas GP.The pathogenesis of hemorrhoids. Dis Colon Rectum. 1984;24:442–50.
23. Sandler RS, Peery AF. Rethinking what we know
about hemorrhoids. Clin Gastroenterol Hepatol.
2019;17(1):8–15.
24. Gao XH, Wang HT, Chen JG, Yang XD, Qian Q, Fu
CG. Rectal perforation after the procedure for prolapse and hemorrhoids: possible causes. Dis Colon
Rectum. 2010;53(10):1439–45.
25. Goligher J. Surgery of the anus, rectum, and colon.
5th ed. London: Bailliere Tindall; 1984.
26. Burkitt DP.Varicose veins, deep vein thrombosis, and
hemorrhoids: epidemiology and suggested etiology.
Br Med J. 1972;2(5813):556–61.
27. Gass OC, Adams J. Hemorrhoids; etiology and
pathology. Am J Surg. 1950;79(1):40–3.
28. El-Gendi MA, Abdel-Baky N.Anorectal pressure in
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29. Ho YH, Seow-Choen F, Goh HS. Haemorrhoidectomy and disordered rectal and anal physiology
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32. Sharif HI, Lee L, Alexander-Williams J. Diathermy
haemorrhoidectomy. Int J Color Dis. 1991;6(4):217–9.
33. Morinaga K, Hasuda K, Ikeda T.A novel therapy for
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artery with a newly devised instrument (Moricorn)
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Gastroenterol. 1995;90(4):610–3.
34. Longo A. Treatment of hemorrhoidal disease by
reducing mucosa and hemorrhoidal prolapse with
a circular stapling device: A new procedure. In:
Proceeding of the 6th World Congress of Endoscopic
Surgery. 1998. p.777–784.
Clinical Evaluation ofHemorrhoids
“Diagnosis is not the end, but the beginning of practice.”
Martin Fischer
4
Key Concepts
• Hemorrhoids may present with bleeding, prolapse, mucosal discharge as chief clinical
complaints.
• Hemorrhoidal bleeding is usually bright red
and painless.
• The best diagnostic tool for a patient with
hemorrhoids is a thorough history and differential diagnosis to rule out other causes.
• Proper positioning of the patient is essential in
the physical examination; the left lateral is the
preferred position.
• Painful rectal bleeding may indicate a ssure
in ano.
• It is imperative to note the color of the blood
that can vary from black to bright red.
• Sigmoidoscopy should be advised in every
patient above 50 presenting with bleeding per
rectum.
• If there is a family history of colorectal cancer, every patient above the age of 40 should
be subjected to a complete colonoscopy.
4.1 Introduction
ten to the patient’s complaints calmly, thoroughly
examine the perianal region, and diagnose. A
thorough and systemic approach helps attain an
appropriate diagnosis.
4.2 Clinical Features
4.2.1 Bleeding
The most common symptom is rectal bleeding,
even before hemorrhoids prolapse [1]. It may be
in the form of dripping in the toilet, spurt, or wiping with tissue paper after defecation [1, 2].
Hemorrhoidal bleeding is usually bright red and
painless (Fig.4.1a, b).
4.2.2 Prolapse
Another common symptom of hemorrhoids is
prolapse (Fig.4.2a, b). Internal hemorrhoids are
classied depending on the degree of prolapse
[3].
Generally speaking, for patients, all anorectal
problems are hemorrhoids. A clinician must lis-
© The Author(s), under exclusive license to Springer Nature Singapore Pte Ltd. 2022
K. Gupta, Lasers in Proctology, https://doi.org/10.1007/978-981-19-5825-0_4
49
50
Fig. 4.1 (a) Active bleeding as seen in second-degree internal hemorrhoids. (b) Active bleeding as seen in external
hemorrhoids
4 Clinical Evaluation ofHemorrhoids
Fig. 4.2 (a) Prolapse of hemorrhoids. (b) Prolapse of hemorrhoids with edema
4.2.3 Thrombosis
canal. It leads to irritation and secretes mucus
[5].
A part or whole of the anal cushion may become
thrombosed [4] (Fig.4.3a, b).
4.2.5 Pain
4.2.4 Mucus Discharge
The columnar mucosa is sometimes exposed
to the outer environment when the prolapse is
substantial enough to extend beyond the anal
Pain with bleeding per rectum during bowel
movements is usually attributed to a ssure in
ano [6]. Bleeding, extreme pain, and occasional
symptoms of systemic disease indicate strangula-
tion of hemorrhoidal masses [7].
ab
4.4 Physical Examination
Fig. 4.3 (a) Thrombosed internal hemorrhoids. (b) Thrombosed external hemorrhoids
51
4.2.6 Pruritus Ani
The inamed mucosa produces mucus that causes
perineal irritation, itching, and soiling [8].
4.2.7 Feeling ofLump
Prolapsed internal hemorrhoids are manifested
by rectal fullness or feeling of incomplete evacuation [1].
– Ease of evacuation
– Constipation
• Family history of colorectal cancer
• Social-economic history
• Any history of weight loss/trauma
• As previous surgery in the anorectal region
may alter the physiological and anatomical
function of the anorectum, a detailed history
should be taken.
4.4 Physical Examination
4.3 History forEvaluation
ofHemorrhoids
The most important diagnostic tool is taking a
proper history of the patient. While taking history, evaluate the patient, focusing on the following aspects:
Proper positioning of the patient is essential in
the physical examination. The preferred position
is left lateral. The buttocks must project over the
table’s edge. The knees and hips are exed to
bring the knees closer to the patient’s chest.
4.4.1 Inspection
• Gender/Age—Common in both the sexes. The
patients are between 25 and 75years of age.
• Dietary habits—Lack of ber diet is one of the
predisposing factors in the development of
hemorrhoids.
• Severity, extent, and duration of symptoms
– Prolapse
– Bleeding
– Presence or absence of pain
• History of bowel habits
– Frequency
– Consistency
Pull the buttocks apart gently. Inspect the anus,
perianal area, perineum, and gluteal folds. Look
for conditions like external hemorrhoids or prolapsing internal hemorrhoids, skin tags, anal ssures, stulas, abscess, anal cancer, warts, and
condyloma. Infection, especially fungal or dermatitis, or scratch marks due to itching, may be
seen. Look for any scar from previous surgery.
The patient may say, “something comes out of
the anal orice at the time of defecation.” Ask the
patient to strain. This will assist in differentiating
52
4 Clinical Evaluation ofHemorrhoids
prolapsed hemorrhoids from rectal prolapse. The
presence of sulci indicates hemorrhoids, whereas
the presence of concentric folds indicates prolapse rectum (Fig.4.4a, b).
4.4.2 Palpation
The perianal region must be palpated for any
swelling before a digital rectal examination
(DRE). While assessing the swelling, observe the
patient’s facial expression. Any indurated painful
swelling on one side of the anus with brawny
edema might indicate an abscess.
4.4.3 Digital Rectal Examination (DRE)
A gentle digital examination is done wearing disposable gloves. The patient should be instructed
to open his mouth and breathe slowly and deeply.
Then, the gloved nger, lubricated with jelly, is
inserted in the anus with a gentle push and rotated
all over to look for abnormalities. Remember that
it is the digit and not the tip of the nger that goes
inside. Patients with ssures may have spasm of
the sphincters and complain of pain during the
digital examination. In such cases, Xylocaine 5%
is inserted in the anus with the help of Foley’s
catheter and left for 15min. After that, the patient
is again taken for DRE.While performing DRE,
look for anal tone, hypertrophic anal papillae,
rectal polyp, benign and malignant growth, and
prostate in males. At the end of the rectal examination, it is advisable to look at the examining
nger for the presence of feces, blood, pus, or
mucus (Tables 4.1 and 4.2).
Table 4.1
Structure in female
Structure in male
Structure
both sexes
Table 4.2 Points to remember before DRE
• Always explain to the patient before doing DRE
• Female patients may feel shy to undergo
• Be gentle while inserting a nger
• In the left lateral posture, examine the patient
• Cover the rest of the parts completely
• Use gloves to examine the patients
• The lighting in the room should be good
Normal structure palpable on DRE
• Perineal body
• Cervix (felt through
vaginal wall)
• Ovaries
• Prostate (anterior)
• Seminal vesic
(anterior)
palpable in
DRE.Always examine such patients in the presence
of a nurse
• Coccyx and s
• Ischial spine
• Anorectal ring
• Intersphincteric groo
• Ischiorectal fossa
les
acrum
ve
Fig. 4.4 (a) Prolapsed hemorrhoids showing presence of sulci. (b) Concentric folds as seen in rectal prolapse
4.4 Physical Examination
53
Contraindications ofDRE
• Patients with severe neutropenia
• Anal stricture
• Acute anal ssure
4.4.5 Symptoms, Signs,
Examination Findings and
Dierential Diagnosis at a
Glance
• Thrombosed external piles
Refer to Tables 4.3, 4.4 and 4.5.
4.4.4 Proctoscopy
DRE alone is insufcient to detect or exclude
internal hemorrhoids. For conrmation of the
diagnosis, a proctoscopy is always necessary.
Always be gentle before inserting the proctoscope. Ask the patient to relax, take a deep breath,
and insert a well-lubricated proctoscope. Take
out the obturator to view the interior of the anal
canal for a clear vision. The red-purple mucosa
with piles will bulge into the proctoscope [9]
(Fig.4.5). Sometimes, hypertrophic anal papillae
are seen. Look for hyperemic rectal mucosa to
rule out inammatory bowel disease.
Table 4.3 Symptoms, signs, examination of hemorrhoids (local and proctoscopy)
Symptoms and Signs
First- degree Second- degree Third-degree Fourth-degree
Painless Bleeding per
rectum bright red.
Burning in the anal region
may or may not be present
Bleeding can be in spurts,
drops, or sometimes on the
toilet paper
Only prolapse of mucosal
moiety as seen on proctoscopy
Painless bleeding per
rectum bright red
Protruding of the
hemorrhoidal mass
during defecation/
straining which
reduces on its own
Anemia may or may
not be present
Fig. 4.5 Hemorrhoids as seen through proctoscopy
Painless Bleeding per
rectum bright red
Protruding of the hemorrhoidal mass during
defecation/straining, which
the patient has to reduce
manually
Mucus discharge Mucus discharge may be
Anemia may or may not be
present
Painless /Painful bleeding
per rectum, bright red and in
a spurt, drops, or seen on
the toilet paper
Prolapsed and irreducible
hemorrhoids lying outside
the anal canal
present
A feeling of incomplete
evacuation
Table 4.4 Examination: Local (L/E) and Proctoscopy examination (P/E)
Examination: Local (L/E) and Proctoscopy examination (P/E)
L/E
Does not show anything
outside
P/E
Small bulges in the lumen
of the anal canal due to the
laxed mucosal moiety
L/E
Does not show
anything outside
locally
P/E
Small bulges in the
lumen of the anal canal
can be seen
L/E
May show hemorrhoidal
masses locally that
reduces manually
P/E
Bulges in the lumen of the
anal canal seen
L/E
Shows prolapsed hemorrhoidal masses locally, which
is not reducible
P/E
Bulges are seen protruding
outside the anal canal that are
irreducible
54
4 Clinical Evaluation ofHemorrhoids
Table 4.5 Differential diagnoses of hemorrhoids [10,
11]
Diagnosis Clinical features Findings
Anal cancer Pain in the anal
area and, in
severe instances,
loss of weight
Anal
condylomas
Colorectal
cancer
Anal ssure Tearing pain and
Perianal
abscess
Inammatory
bowel disease
Rectal polyp Changing stool
Skin tags No bleeding Around the anus,
Rectal
prolapse
Anal intercourse
history anal mass
without bleeding
Blood in stool,
weight loss,
changing bowel
habits, abdominal
pain, family
history
bleeding with
bowel movement
Pain onset
gradually
Constitutional
signs, abdominal
pain
color, rectal
bleeding, excess
mucus, pain, iron
deciency
anemia, changing
bowel habits (i.e.,
frequency),
abdominal pain
Pain, blood and
mucus, constipation, incomplete
evacuation,
difculty in
passing motion,
protrusion of the
rectum through
the anus
Ulcerating lesion
of the anus
Cauliower like
lesions
Abdominal mass
or tenderness
Examining the
anal canal in a
ssure is painful
In contrast to the
rectal mucosa,
this mass is
covered with
sensitive skin
Abdominal mass
or tenderness
Mushroom-like
growth in the
anal canal
tags are
visualized
Concentrically
arranged
mucosal folds
should easily
distinguish
complete rectal
prolapse
4.5 Evaluation andClinical
Correlation ofAnorectal
Symptoms
4.5.1 Rectal Bleeding
Bleeding per rectum is one of the most familiar
complaints of anorectal patients requiring medical or surgical intervention. Most patients with
painless rectal bleeding are patients with hemorrhoids [12]. Painful rectal bleeding may indicate
a ssure in ano. When bleeding is associated with
diarrhea, inammatory bowel disease should
always be considered (Table 4.6). Rectal cancer
can exhibit symptoms of painful bleeding and
tenesmus. It is imperative to note the color of the
blood that can vary from black to bright red [12].
• Dark, mahogany, or maroon color may indi-
cate carcinoma rectum or bleeding from the
upper GI tract.
• No frank blood in the stool but positive occult
blood indicates the necessity of a gastrointestinal evaluation.
4.5.2 Pain
Continuous pain which is not associated with
defecation is indicative of anorectal abscess or
thrombosed hemorrhoids. Pain associated with
defecation is suggestive of anal ssure. Deepseated throbbing pain with difculty in sitting
indicates a perianal abscess. An intermittent
deep-seated pain unrelated to defecation indicates proctalgia fugax. Pain in the coccyx area
associated with discharge from an opening in the
coccyx region indicates pilonidal sinus.
Continuous pain may indicate pudendal nerve
entrapment syndrome. The carcinoma rectum
may be associated with tenesmus. In Levator ani
syndrome, the patient reports dull pain in the rec-
4.6 Diagnostic Evaluations
Table 4.6 Causes of rectal bleeding [12]
Anal causes Rectal causes Colonic causes General causes
Hemorrhoids Angiodysplasia Diverticular disease Clotting deciencies
Anal ssure Ischemia Infective Anticoagulants
Anal stula Infective Inammatory Uremia
• Ulcerative colitis
• Crohn’s disease
Perianal hematoma Inammatory Intussusception
Condylomas Solitary rectal ulcer syndrome Neoplasia
Trauma Neoplasia Angiodysplasia
Malignancy
55
Table 4.7 Summary of correlation between pain and
bleeding PR [14]
Findings Possibility
Painless bleeding PR Hemorrhoids
Painful bleeding PR Anal ssure
Bleeding PR with pain and
tenesmus
Carcinoma anus or
rectum
tum that worsens as he sits [13]. It usually persists for 20min after defecation (Table4.7).
4.5.3 Perianal/Rectal Mass
They may include perianal abscesses, external
hemorrhoids, condylomas, skin tags, and anal carcinoma. The possibility of neoplasm should
always be kept in mind irrespective of age.
Approximately 80% of rectal neoplasms are
within the range of digital examination [11, 12]. It
is always necessary to assess mobility and persistence of growth. Local tenderness may indicate
the presence of ssure, abscess, or hematoma.
Table 4.8 Common causes of rectal discharge [16]
Discharge of mucus Discharge of pus
Rectal prolapse Perianal Crohn’s
disease
Hemorrhoids Anal stula
Solitary rectal ulcer
syndrome
Villous adenoma Syphilis and gonorrhea
Carcinoma of the rectum Anal neoplasm
Proctitis Condyloma
Anal tuberculosis
4.6 Diagnostic Evaluations
4.6.1 Sigmoidoscopy
The distal colon is inspected up to 40cm from the
anal verge using a sigmoidoscope introduced into
the anal canal. A solitary rectal ulcer should
always be ruled out, typically present anteriorly
about 8 cm from the anal verge. If required, a
therapeutic procedure is carried out [17].
4.6.2 Colonoscopy
4.5.4 Mucus Discharge
Mucus discharge from the anal area is one of
the complaints of anorectal diseases. A purulent
discharge may indicate perianal and anal sepsis. A blood-stained mucus discharge associated with diarrhea indicates Ulcerative colitis
or Crohn’s disease [15]. A copious secretion is
always indicative of neoplasia. These types of
secretions lead to skin irritation and pruritus
(Table4.8).
According to the ASCRS (American Society of
Colon and Rectal Surgeons) clinical practice recommendations, patients experiencing hemorrhoidal symptoms like prolapse and rectal bleeding
should have a comprehensive endoscopic examination of the colon and rectum [18]. It is an essential
investigation in evaluating rectal bleeding that may
not be from hemorrhoids and may help exclude
other risk factors like malignancy of the colon or
rectal bleeding with no prominent clinical ndings
on anorectal examination [14].
56
ASCRS Clinical Practice Guidelines for
Sigmoidoscopy and Colonoscopy
Sigmoidoscopy should be advised in every
patient above age of 50 presenting with
bleeding per rectum. In case there is a family history of colorectal cancer, all patients
above the age of 40years should be subjected to complete colonoscopy [18].
Although hemorrhoids are not cause of
anemia, yet all the young patients with
bleeding per rectum should be subjected to
colonoscopy irrespective of age.
When no source of bleeding is seen on
anorectal examination, the bleeding is unusual
for hemorrhoids, anemia or occult blood present in the stool, or possibility of colonic neoplasia exist, a total colon examination through
colonoscopy is recommended.
4 Clinical Evaluation ofHemorrhoids
Table 4.10 Indication and contraindications of sigmoidoscopy [17]
Indications of sigmoidoscopy
• Evaluation of distal colon/sigmoid
Contraindications
• Acute diverticulitis
• Bowel perforation
• Fulminant colitis
• Active peritonitis
• Anal Fissure
• Cardiopulmonary instability
Take-Home Message
• A thorough examination of the anal region
helps in making a denitive diagnosis. An
essential clinical nding for determining the
source of bleeding is observing the color of
the blood. Colonoscopy or sigmoidoscopy
should be considered mandatory while evaluating a patient with a rectal bleed.
4.7 Indications
andContraindications
ofColonoscopy
andSigmoidoscopy (Tables
4.9 and4.10)
Table 4.9 Indication and contraindications of colonos-
copy [19]
Indications of colonoscopy
• Bleeding per rectum
• Evaluation of inammatory bowel disease
• Screening of cancer
• Endoscopic removal of polyps
• Colonic stent placement
• Endoscopic submucosal dissection
Contraindications
• Uncooperative patients
• Suspected or known colonic perforation
• Inadequate sedation
• Clinically unstable patients
• Severe fulminant colitis and toxic megacolon
• Peritonism
• Inadequate bowel preparation
• Recent myocardial infarction
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