I have specialized in the minimally invasive treatment of hemorrhoids. Every healthy person has hemorrhoids. Only the enlarged hemorrhoids are pathological. The term “haemorrhoids” or also “hemorrhoids” (both spellings are possible) comes from the Greek and means “blood” and “flow”.

What are hemorrhoids?

Haemorrhoids are ring-shaped vascular cushions on the inner upper edge of the anal canal, which seal the intestine like a sealing rubber. They are responsible for the gas- and watertight seal (fine continence) of the intestine. While the sphincter muscle is responsible for approx. 80% of the tightness (continence performance), the haemorrhoids account for approx. 20%.

Only in the case of swelling with symptoms are we talking about haemorrhoids in the true sense of the word.

In the vernacular, everything hanging or enlarged on the anus and in the rectum is erroneously called haemorrhoids. However, the professional differentiation of haemorrhoids from other diseases is necessary to choose the right treatment. It is performed by a specialist, the proctologist. This involves an inspection from the outside with the buttocks spread apart, a rectal palpation with the finger and finally a reflection of the anal canal. In the case of acute pain conditions, an external inspection is usually sufficient to determine the pain-causing disease (gaze diagnosis). It is then treated with medication and the examination is later completed in a painless state.

Symptoms of haemorrhoids

An enlargement of the hemorrhoidal cushions can lead to a variety of symptoms and secondary diseases. The most common symptom is itching, followed by bleeding. Other symptoms are: Burning, pain, wetting, smearing of stool, swelling/prolapse, disturbance of the controlled release of intestinal gases (discrimination), feeling of pressure, rectal cramps, urge to defecate with shortened warning time, feeling of blockage with delayed defecation and pressing, feeling of incomplete defecation, increased feeling of flatulence, repeated occurrence of anal eczema, anal vein thrombosis, cryptitis, proctitis.

Causes of hemorrhoids

The causes for an increase in hemorrhoids are complex. In the first place, unhealthy lifestyle and incorrect nutrition and drinking habits are the main causes. These include a diet low in fibre but rich in fat and carbohydrates, soft drinks, alcohol and spicy food. In addition, there is a lack of exercise (sedentary activity), stress, overweight, heavy lifting and carrying, long toilet sessions, pressing when defecating. Interestingly, these are the same causes as for diverticular disease.

Our diet, which is rich in fat and protein but low in fibre, results in a rather compact faeces (defecation, lat.: faeces). Normally, the wall of the colon needs a sufficient stretching stimulus from the faeces to trigger a peristaltic wave. Peristalsis is the unconscious segmental activation of the intestinal muscles to propel the faeces. The passage time of the compact faeces in the intestine is prolonged due to the missing stretching stimulus. This effect is intensified by low drinking quantities and lack of movement. In addition, stress reduces the intestinal movement and the time of defecation is determined by our environment. Defecation is thus made more difficult. The consequences can be “pressing” and “long sessions” on the toilet (“Finally I can go to the toilet in peace.”).

The pressing increases the pressure in the pelvic floor and blood is pressed into the hemorrhoidal cushion (lat.: Plexus hemorrhoidalis superior). However, the pressure in the pelvic floor prevents emptying of the haemorrhoidal cushion, which normally takes place before defecation (defecation). The cushion swells. Initially, this congestion disappears again after the pressing is finished. If this process is repeated over months and years, the congestion remains permanent. Grade 1 haemorrhoids develop.

Classification of hemorrhoids

Enlarged hemorrhoids are classified into 4 degrees.

However, there are smooth transitions between the grades and the symptoms also vary widely. Similarly, haemorrhoids of different degrees can coexist simultaneously.

Grade 1 means a slight enlargement / congestion which is only localised in the rectum and is not visible from the outside. It can only be detected by examination with a tubular visual instrument (proctoscope). The congestion causes barely noticeable leakage from the anus.

Typical symptoms of grade 1 hemorrhoids are: Itching, burning, bleeding, rectal cramps.

With grade 1 haemorrhoids, a complete cure is spontaneously possible in 70% of cases.

Parallel to the development of grade 1 haemorrhoids, congestion may occur in the external vein cushion located at the anal edge (lat.: inferior hemorrhoidal plexus). Due to the overstretching of the anal skin lining the anal canal and spanning the vein cushions, an anal prolapse develops within years.

If the congestion of the hemorrhoidal cushions described above persists, it leads to an enlargement of the hemorrhoidal nodes. The nodes are then pushed by the faeces in front of them into the anal canal during pressing during defecation and thus briefly emerge outwards (haemorridal prolapse). If the pressing pressure decreases, a spontaneous retraction of the prolapse occurs. The haemorrhoidal nodes return to their original location at the upper edge of the anal canal. This is grade 2 haemorrhoids, unlike anal venous thrombosis, which can be felt for several days to weeks before it has dissolved again.

Grade 2 means a strong enlargement localized internally in the rectum and visible from the outside only when the buttocks are strongly abducted. Just like grade 1 haemorrhoids, they can only be visualised beyond doubt by examination with a proctoscope. The leakage of the anus can now be felt.

Typical symptoms of grade 2 haemorrhoids are Itching, burning, bleeding, oozing, greasy stool, foreign body sensation. Those affected describe that the sphincter muscle would no longer seal properly.

If the causes of hemorrhoids are not stopped at this point, the prolapse of anal skin and hemorrhoids increases. The haemorrhoidal cushion covered by a mucous membrane is normally attached to its muscular base by short strands of connective tissue. Due to the oversized filling conditions during congestion, the connective tissue strands are overstretched and irreversibly transformed. Before pressing during defecation, the natural emptying of the blood cushion no longer occurs. The haemorrhoids are forced out of the anal canal and give way to the pressure externally to the side. A return into the anal canal is only possible by hand or takes place very gradually over a longer period of time. Due to the anal prolapse which now always accompanies this process, these haemorrhoids are already visible externally during the examination after pressing. However, they can be pushed back into the anal canal during an examination and remain there for the most part. This is typical for grade 3 haemorrhoids.

Grade 3 means externally visible haemorrhoids that can be repositioned inwards (prolapse reduction) during examination.

Typical symptoms of grade 3 hemorrhoids are Itching, burning, bleeding, weeping, mucus discharge, prolapse (prolapse), stool smearing with anal hygiene problems. (“Although I wash thoroughly after bowel movements, I do not get clean.”)
The removal of haemorrhoids from grade 3 or an anal prolapse is usually only possible by surgery. In rare cases, however, a serial treatment with rubber band ligatures can also help.

Grade 4 means externally visible haemorrhoids which cannot be permanently returned to the inside during examination. A distinction can be made between grade 4a (which can be pushed back by an examination, but pushes out again immediately after the examination is completed) and grade 4b (the prolapse can no longer be pushed back by an examination with the finger).

Haemorrhoids grade 4b are equivalent to a fixation of the anal and haemorridal prolapse.

The division into grade 4a and grade 4b is important for the choice of treatment. Thus still traceable haemorrhoids can be operated on very well using the Longo method.

Due to discharge, haemorrhoids often cause irritation of the skin around the anus (anal eczema). Haemorrhoids are the most common cause of anal eczema. However, there are many other causes of anal eczema that need to be differentiated. The itching of haemorrhoids is increased by anal eczema and can become chronic.

Treatment of hemorrhoids

The treatment of haemorrhoids is divided into a basic therapy and a specific therapy.

The basic therapy consists of adjusting the amount of drinking, physical activity and fibre-rich nutrition while avoiding excessively spicy food or alcohol consumption. The aim is a voluminous soft-formed bowel movement, which is defecated without pressing and “long sessions”. Under basic therapy, grade 1 haemorrhoids can heal spontaneously and higher grade haemorrhoids become symptom-free. The basic therapy also serves as a prophylaxis before renewed hemorrhoids after specific therapy.

The specific therapy is divided into symptom-relieving and haemorrhoid-reducing therapy. Symptom-reducing means that the haemorrhoids are no longer noticeably annoying. However, they are still present in an enlarged form (grades 1-4) and may be palpable. Haemorrhoid-reducing therapy means that the enlarged haemorrhoidal cushions are brought back to their normal size necessary for sealing the anal canal. In the vernacular the hemorrhoids are “eliminated”, but this is not true.

The symptom-relieving specific therapy for all hemorrhoids grades 1-4 can usually be carried out very well initially with suppositories or ointments. There are also a lot of freely available “haemorrhoid” suppositories and ointments on the market. Whether they are purely plant-based or contain chemically synthesised active ingredients, they have a local anaesthetic and anti-inflammatory effect.

In most cases, this form of therapy is carried out on the patient’s own initiative, on the advice of the pharmacist or family doctor, even before consulting a proctologist. It is very effective in most cases of haemorrhoids of all degrees in combination with the basic therapy. However, I cannot give a general recommendation due to the very individual allergy readiness of each person.

Specific hemorrhoid-reducing therapies:

Grade 1 and 2 haemorrhoids: Sclerotherapy – This involves injecting a sclerosing agent into the haemorrhoidal node, which reduces the volume of the node through a local inflammatory reaction. This leads to a reduction of the congestion. read more

Haemorrhoids grade 2 and 3: Rubber band ligation – A small rubber band is put over a part of the enlarged haemorrhoidal knot to pinch off the inner protruding part of the knot. After the constricted tissue has died off, it is excreted unnoticed together with the rubber band during defecation after about 2 days. read more

Grade 3 and 4 hemorrhoids: surgery – in principle, the non-surgical procedures (sclerotherapy or rubber band ligation) can also be used for more severe hemorrhoids. However, the higher the degree, the lower is the probability of their effect and the duration of their effect.

The choice of the surgical method depends on the type of hemorrhoidal prolapse (fixed or not) and the number of nodes (only one node or circular) and is an individual decision between patient and doctor:

– Operation according to Milligan-Morgan, Ferguson or Parks – especially suitable for single nodules. Here, the enlarged nodule is peeled out while sparing the anal skin as much as possible.

– Operation after Longo (stacker haemorridopexy) – especially suitable for well traceable anal and/or haemorrhoidal prolapse, Here a mucous membrane ring is punched out internally above the haemorrhoids by means of a stacker and the prolapse is thereby retracted and internally fixed.

– Operation according to Fansler-Arnold – particularly suitable for fixed prolapse. The prolapsed anoderm is swivelled into the anal canal over a large area after peeling off the haemorrhoidal pads.

– HAL/ RAR/ THD – especially suitable for haemorrhoids grade 2-3 without fixation. The haemorrhoidal artery ligation (HAL) method uses vascular ultrasound to locate the artery radiating into the haemorrhoidal nodules from above and to stop it with a suture stitched around the artery. The mucosa above the haemorrhoids is additionally gathered by piercing and removing the same suture several times and then pulling and tying the two suture ends together (RAR – rectoanal repair). THD (Transanal Hemorrhoid Dearterialization) is an identical method, only named differently by the manufacturer of the surgical instrument.

– Infrared coagulation – It is used in cases of heavily bleeding haemorrhoids I.-II. degree. The heat of the infrared light welds the hemorrhoid pad.

– HELP (Hemorrhoidal Laser Procedure) – “small laser sclerotherapy” especially suitable for hemorrhoids grade 1-2. Similar to HAL, vascular ultrasound is used to detect the artery entering the hemorrhoidal nodules from above and close it by photocoagulation with the laser. Read more …

– LHP (Laser Hemorrhoidoplasty) – “large laser sclerotherapy” particularly suitable for haemorrhoids grade 3-4, a completely new procedure that does not require large incisions. The laser probe is inserted directly into the enlarged haemorrhoid nodules through only 4 stitches and these are shrunk by photocoagulation. This is currently the most gentle procedure for the treatment of higher grade hemorrhoids. Read more …