Hemorrhoids, also called piles, are swollen and inflamed veins in the anus and lower rectum and can be external or internal. When internal hemorrhoids become quite large and protrude outside the anus, they're called prolapsed hemorrhoids and can cause pain and bleeding and lead to more serious complications if not treated.
The Degrees of Prolapsed Hemorrhoids
There are four degrees of prolapsed hemorrhoids. With a first-degree hemorrhoid, the internal hemorrhoid doesn't protrude outside the anal canal. With a second degree, the hemorrhoid retracts on its own and doesn't require special treatment. The third degree is a little worse, and the hemorrhoid will need to be manually placed back inside the anal canal. The most severe prolapsed hemorrhoid, or fourth degree, occurs when the prolapsed hemorrhoid can't be replaced and hangs outside the anus in what becomes a chronic condition. Fourth-degree cases are often thrombosed (swelling with blood) and are extremely painful.
Minimally Invasive Remedies
Prolapsed hemorrhoids can be treated with minimally invasive procedures performed in your doctor's office or other outpatient setting. These include the following:
Rubber band ligation: One or two tiny rubber bands are placed around the base of the hemorrhoid to cut off its circulation, and within a few days, the hemorrhoid withers and falls off. This treatment can be uncomfortable and may cause bleeding, but such side effects are rarely severe. It's the most widely used procedure in the U.S. for prolapsed hemorrhoids that are first or second degree.
Injection (sclerotherapy): A chemical solution is injected into the hemorrhoid tissue to shrink it. The procedure isn't usually painful, but it's also not as effective as rubber band ligation. Sclerotherapy is sometimes used in combination with rubber land ligation for maximum results.
Coagulation: Different techniques are used to harden the hemorrhoids and make them shrivel. These techniques include laser light; an infrared light in which a device called a photocoagulator focuses infrared light into a fine point at the end of a probe, welding the hemorrhoid in place; and electrotherapy. With these treatments, pain is frequently experienced, although it's usually less frequent than with ligation.
Cryotherapy: Cryotherapy uses cold temperature to obliterate the veins, causing inflammation and scarring. It's not commonly used, however, because it is more time consuming, causes more post-treatment pain and is less effective than other treatments.
Although most patients with prolapsed hemorrhoids can manage their condition with non-surgical treatments, a small number--less than 10 percent--will require surgery, especially if the hemorrhoids aren't treated early. If surgery is required, it can take one of the following forms:
Dilation: The anal canal is forcefully stretched to weaken the anal sphincter. However, dilation can damage the sphincter itself and many patients become incontinent or unable to control their stool.
Doppler ligation: Using a Doppler probe that measures blood flow, a doctor identifies the artery supplying the hemorrhoidal vessels, then ties off (ligates) the artery, causing the hemorrhoid to shrink. The Doppler probe is expensive and doesn't offer many advantages over rubber band ligation.
Sphincterotomy: Part of the sphincter is cut in an effort to reduce the pressure of the sphincter within the anal canal. The procedure can cause stool incontinence and is rarely used by itself.
Hemorrhoidectomy: Surgical removal of hemorrhoids (hemorrhoidectomy) is reserved for patients with third- or fourth-degree hemorrhoids. With hemorrhoidectomy, the internal hemorrhoids are cut out, and the wounds left by the removal are stitched together (closed technique) or left open (open technique). In some cases, a proctoplasty--removal of tissue higher into the anal canal--is performed at the same time. The major side effect of hemorrhoidectomy is post-surgical pain, often requiring potent narcotic pain medications, and patients are unable to return to work for two to four weeks.
Stapled hemorrhoidectomy: This is one of the newest surgical techniques for treating hemorrhoids, and is becoming more popular for treating third-degree hemorrhoids. During the procedure, a hollow circular tube is inserted into the anal canal, then a long thread is woven through the tube above the hemorrhoids. A disposable stapler instrument is placed through the tube and the ends of the thread are pulled, "stapling" the hemorrhoidal cushions back up into their normal position.
Laser surgery: A laser beam of light is pointed at the hemorrhoid, vaporizing it with precision and accuracy. In general, laster procedures result in rapid healing with less discomfort and less medication. Lasers can be used alone or in combination with other treatments.
Atomizing hemorrhoids: Another new technique to remove hemorrhoids uses a medical device that reduces the hemorrhoidal tissue to minute particles into a fine mist or spray, which is immediately vacuumed away.
Early complications of any hemorrhoid surgery can include severe postoperative pain, sometimes lasting two to three weeks; infections; abscesses; post-operative bleeding; swelling of the skin bridges; major short-term incontinence; and difficulty with urination. Later complications can include anal stenosis, where the anal opening is too small or doesn't relax or open properly; the formation of skin tags; anal fissure; incontinence; fecal impaction (usually caused by narcotic use); delayed hemorrhaging; and blood clots.
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