Visual confirmation of internal hemorrhoids may require anoscopy, insertion of a hollow tube device with a light attached at one end. The two types of hemorrhoids are external and internal. These are differentiated by their position with respect to the pectinate line. Some persons may concurrently have symptomatic versions of both. If pain is present, the condition is more likely to be an anal fissure or external hemorrhoid rather than internal hemorrhoid. Internal
Internal hemorrhoids originate above the pectinate line. They are covered by columnar epithelium, which lacks pain receptors. They were classified in 1985 into four grades based on the degree of prolapse:
Grade I: No prolapse, just prominent blood vessels
Grade II: Prolapse upon bearing down, but spontaneous reduction
Grade III: Prolapse upon bearing down requiring manual reduction
Grade IV: Prolapse with inability to be manually reduced. External
External hemorrhoids occur below the dentate (or pectinate) line. They are covered proximally by anoderm and distally by skin, both of which are sensitive to pain and temperature. Differential
Many anorectal problems, including fissures, fistulae, abscesses, colorectal cancer, rectal varices, and itching have similar symptoms and may be incorrectly referred to as hemorrhoids. Rectal bleeding may also occur owing to colorectal cancer, colitis including inflammatory bowel disease, diverticular disease, and angiodysplasia. If anemia is present, other potential causes should be considered.Other conditions that produce an anal mass include skin tags, anal warts, rectal prolapse, polyps, and enlarged anal papillae. Anorectal varices due to portal hypertension (blood pressure in the portal venous system) may present similar to hemorrhoids but are a different condition.
Doppler-guided transanal hemorrhoidal dearterialization is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications compared to a hemorrhoidectomy. Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomical position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids. However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorrhoidectomy, so it is typically recommended only for grade II or III disease. Epidemiology
It is difficult to determine how common hemorrhoids are as many people with the condition do not see a healthcare provider. However, symptomatic hemorrhoids are thought to affect at least 50% of the US population at some time during their lives, and around 5% of the population is affected at any given time. Both sexes experience about the same incidence of the condition, with rates peaking between 45 and 65 years. They are more common in Caucasians and those of higher socioeconomic status.Long-term outcomes are generally good, though some people may have recurrent symptomatic episodes. Only a small proportion of persons end up needing surgery.