A Pain in the @$$

"Say Cheese!"

Just like lower back pain, asymptomatic hypertension, and headaches, a bleeding anus--specifically hemorrhoidal--can often be a royal pain in the you-know-what (ok, pun intended there). Probably because there are so many treatment options available, both conservatively and invasively, for this highly prevalent nuisance we often stumble or even fall short in our ED-based management of these little bloody butt dwellers.

This post serves to clarify (and simplify!) diagnosis and classification of hemorrhoids--sometimes a challenge in and of itself--so that proper evidence-based and guideline supported management may be followed.

The first step in correctly managing hemorrhoids is correct diagnosis. While a full discussion of perianal disease is beyond the scope of this posting, essentially our first task is to differentiate between internal and external hemorrhoids.

1. History: while the old dogma of internal hemorrhoids being painless and external hemorroids (when thrombosed) being painful probably holds true there are other clues in the history that may assist in your differentiation. Internal hemorrhoids prolapse with Valsalva and reduce spontaneously (stage II) or manually (stage III), unless they are incarcerated (Stage IV), in which case they are an emergency. External hemorrhoids are, well, always external.

2. Physical: look at the overlying skin. External hemorrhoids share the same epithelium as the surrounding anus so the appearance is essentially the same. Internal hemorrhoids are covered by mucosa and carry a shinier wet appearance--or at least are unlike the surrounding external tissue.

Management:

If you grouped all hemorrhoid types and grades therein, you find three basic courses of action that you, as the emergency physician, can take. Presented in order of increasing immediacy, they are:

1. TLC or Therapeutic Lifestyle Changes - are essential in all cases and varieties of hemorrhoids and should always be recommended. According to the literature, simple TLC--especially in cases of non-thrombosed external and low-grade internal hemorrhoids--alleviates symptoms and decreases hemorrhoid size (sometimes entirely). A plethora of OTC supplements and such exist, however the most efficacious (and supported) are sitz baths, fiber dietary supplements, and topical analgesics. See here for more detail.

2. Excision of thrombus - When an external hemorrhoid clots, an excision--not incision and drainage--is indicated if presentation is within 72 hours of symptom onset. If patients come in later, spontaneous dissolution and resorption occurs and conservative management (TLC) is acceptable. A quick video illustrating the procedure can be viewed here.

3. Call a surgeon. With hemorrhoids, there are basically two reasons to immediately involve your specialist: stage IV internal hemorroids and clotted circumferential external hemorrhoids (or at least too big to handle yourself). Also, never incise or excise internal hemorrhoids--thrombosed or not. Have a surgeon take a look.

"I will find all your hidden treasures."

Sources:

http://www.ncbi.nlm.nih.gov/pubmed/20109630

http://www.fascrs.org/gedownload!/Practice_Parameters_for_the_Management_of_Hemorrhoids.pdf?item_id=12244001&version_id=12244002

http://www.ncbi.nlm.nih.gov/pubmed/22534276