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- Varicosities of the hemorrhoidal venous plexus
- External hemorrhoids
- Located below the dentate line (painful)
- Covered by squamous epithelium
- Internal hemorrhoids
- Located above the dentate line (painless)
- Both types of hemorrhoids often coexist.
- Classification of internal hemorrhoids:
- 1st-degree: Hemorrhoids do not prolapse.
- 2nd-degree: prolapse through the anus on straining but reduce spontaneously
- 3rd-degree: protrude and require digital reduction
- 4th-degree: cannot be reduced
- Hemorrhoids often progress from itching and bleeding to protrusion with easy reduction, then difficult reduction, and finally, rectal prolapse. Thrombosis may occur at any stage of protrusion. External hemorrhoids cause pain; internal hemorrhoids generally do not (1).
Hemorrhoids are more common in elderly, as is rectal prolapse.
- Uncommon in infants and children; when discovered, look for underlying cause (e.g., vena caval or mesenteric obstruction, cirrhosis, portal hypertension [HTN]).
- Occasionally, as in adults, hemorrhoids may result from chronic constipation, fecal impaction, and straining at stool; surgery rarely required in children
- Common in pregnancy
- Usually resolves after pregnancy
- No treatment required, unless extremely painful
- Predominant age: adults; peak from 45 to 65 years
- Predominant sex: male = female
~4–5% in general population in the United States
Etiology and Pathophysiology
- There are three primary hemorrhoidal cushions—typically located in left lateral, right anterior, and right posterior positions. Hemorrhoidal cushions augment anal closing pressure and protect the anal sphincter during stool passage. During Valsalva, increased intra-abdominal pressure raises pressure within the hemorrhoidal cushions. Mechanisms implicated in symptomatic hemorrhoidal disease include:
- Dilated veins of hemorrhoidal plexus
- Tight internal anal sphincter
- Abnormal distention of the arteriovenous anastomosis
- Prolapse of the cushions and the surrounding connective tissues
No known genetic pattern
- Pelvic space-occupying lesions
- Liver disease; portal HTN
- Occupations that require prolonged sitting
- Loss of perianal muscle tone due to old age, rectal surgery, birth trauma/episiotomy, anal intercourse
- Chronic diarrhea
- Avoid constipation by consuming high-fiber diet (>30 g/day) and ensuring proper hydration.
- Maintain appropriate weight.
- Avoid prolonged sitting or straining on the toilet.
Commonly Associated Conditions
- Liver disease; portal HTN