The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids

The American Society of Colon and Rectal Surgeons (ASCRS) is dedicated to assuring high-quality patient care by advancing the science, prevention, and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Committee is composed of Society members who are chosen because they have demonstrated expertise in the specialty of colon and rectal surgery. This committee was created to lead international efforts in defining quality care for conditions related to the colon, rectum, and anus. This is accompanied by developing Clinical Practice Guidelines based on the best available evidence. These guidelines are inclusive and not prescriptive. Their purpose is to provide information on which decisions can be made rather than to dictate a specific form of treatment. These guidelines are intended for the use of all practitioners, healthcare workers, and patients who desire information about the management of the conditions addressed by the topics covered in these guidelines. It should be recognized that these guidelines should not be deemed inclusive of all proper methods of care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regarding the propriety of any specific procedure must be made by the physician in light of all of the circumstances presented by the individual patient. STATEMENT OF THE PROBLEM Symptoms related to hemorrhoids are very common in the Western hemisphere and other industrialized societies. Although published estimates of prevalence are varied,1,2 it represents one of the most common medical and surgical disease processes encountered in the United States, resulting in >2.2-million outpatient evaluations per year.3 A large number of diverse symptoms may be, correctly or incorrectly, attributed to hemorrhoids by both patients and referring physicians. As a result, it is important to identify symptomatic hemorrhoids as the underlying source of the anorectal symptom and to have a clear understanding of the evaluation and management of this disease process. These guidelines address both diagnostic and therapeutic modalities in the management of hemorrhoidal disease. METHODOLOGY These guidelines are built on the ASCRS Practice Parameters for the Management of Hemorrhoids published in 2011.4 A literature search of MEDLINE, PubMed, and the Cochrane Database of Collected Reviews was performed, expanding on the previous literature search from 1996 and updated through April 2017 (see Supplemental Search Strategy, https://links.lww.com/DCR/A532). Key word combinations included hemorrhoid, internal and external hemorrhoids, hemorrhoid disease, thrombosed hemorrhoid, rubber band ligation, hemorrhoidopexy, procedure for prolapse and hemorrhoids (PPH), and stapled hemorrhoidopexy, Doppler-guided hemorrhoidopexy, hemorrhoidectomy, Milligan–Morgan, and Ferguson. Directed searches of the embedded references from the primary articles were also performed in selected circumstances. The final source material used was evaluated for the methodologic quality, the evidence base was examined, and a treatment guideline was formulated by the subcommittee for this guideline. When agreement was incomplete regarding the evidence base or treatment guideline, consensus from the committee chair, vice chair, and 2 assigned reviewers determined the outcome. The final grade of recommendation and level of evidence for each statement were determined using the Grades of Recommendation, Assessment, Development, and Evaluation system (Table 1).1,5 Members of the ASCRS Clinical Practice Guidelines Committee worked in joint production of these guidelines from inception to final publication. Recommendations formulated by the subcommittee were then reviewed by the entire Clinical Practice Guidelines Committee for edits and recommendations. Final recommendations were approved by the ASCRS Clinical Guidelines Committee and ASCRS Executive Committee. In general, each ASCRS Clinical Practice Guideline is updated every 3 to 5 years.TABLE 1.: The Grades of Recommendation, Assessment, Development, and Evaluation System Grading RecommendationsEVALUATION OF HEMORRHOIDS 1. A disease-specific history and physical examination should be performed, emphasizing degree and duration of symptoms and risk factors. Grade of Recommendation: Strong recommendation based on low-quality evidence, 1C. The diagnosis of hemorrhoids is almost always a clinical one and should start with a medical history, with great care taken to identify symptoms suggestive of hemorrhoidal disease and risk factors such as constipation,6 followed by a focused physical examination. The cardinal signs of internal hemorrhoids are painless bleeding with bowel movements with intermittent protrusion. Focus should be on the extent, severity, and duration of symptoms such as bleeding and prolapse, issues of perineal hygiene, and presence or absence of pain. A careful review of fiber intake and bowel habits, including frequency, consistency, and ease of evacuation, should also be performed, because constipation predisposes patients to hemorrhoidal disease.6,7 A careful assessment of fecal incontinence symptoms should also be made, because this may affect management decisions, to include the possibility of surgical treatment. Physical examination in the prone, knee–chest, or lateral decubitus position should include visual inspection of the anus, as well as digital rectal examination to evaluate for other anal pathology and sphincter integrity. In addition, an evaluation of the patient while straining on the bathroom will assist in the diagnosis of hemorrhoidal prolapse, as well as exclude full-thickness rectal prolapse. An anoscopic examination should be performed to assess the anatomy.8 Internal hemorrhoids, located above the dentate line, can be assigned a grade based on the definitions in Table 2, which may help to guide therapy. Laboratory evaluation is not typically required for diagnostic purposes.TABLE 2.: Classification of Internal HemorrhoidsEVALUATION OF RECTAL BLEEDING 1. Complete endoscopic evaluation of the colon is indicated in select patients with symptomatic hemorrhoids and rectal bleeding. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B. Although hemorrhoidal disease is the most common reason for hematochezia, other disease processes, such as colorectal cancer, IBD, other colitides, diverticular disease, and angiodysplasia, can also precipitate bleeding.9 While the majority of patients with hematochezia will not have colorectal cancer, rectal bleeding attributed to hemorrhoids represents the most common missed opportunity to establish a cancer diagnosis.10 Obtaining a thorough personal and family history and a physical examination, which may include proctoscopy and/or flexible sigmoidoscopy, will identify high-risk patients requiring more extensive evaluation. Previous endoscopy records should be reviewed, when available. Those who fulfill select criteria set in Table 3 should have a full colonic evaluation with colonoscopy or other colorectal cancer screening modality.11 Patients unable to undergo colonoscopic evaluation may be considered for flexible sigmoidoscopy combined with other diagnostic modalities per consensus guidelines.12TABLE 3.: Indications for Complete Colon EvaluationMEDICAL TREATMENT OF HEMORRHOIDS 1. Dietary modification consisting of adequate fluid and fiber intake and counseling regarding defecation habits typically form the primary first-line therapy for patients with symptomatic hemorrhoid disease. Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B. Constipation and abnormal bowel habits (eg, straining, prolonged sitting, and frequent bowel movements) can play a significant role in patients with symptomatic hemorrhoids.6,7 Increased fiber and fluid intake should be recommended to all patients and have been shown to improve symptoms of mild-to-moderate prolapse and bleeding. A Cochrane review including 7 randomized trials and a total of 378 participants compared fiber with a nonfiber control and showed that fiber had a beneficial effect in the treatment of symptomatic hemorrhoids (risk reduction (RR) = 0.47 (95% CI, 0.32–0.68)). The effect on bleeding showed a significant difference in favor of fiber supplementation (RR = 0.50 (95% CI, 0.28 to 0.89)), whereas symptoms such as prolapse, pain, and itching showed a tendency toward no effect.13 Patients should also be counseled as to maintaining proper bowel habits, such as avoidance of straining and limiting time on the commode, because these practices have been associated with higher rates of symptomatic hemorrhoids.14,15 2. Medical therapy for hemorrhoids represents a heterogeneous group of treatment options that can be offered with expectations of minimal harm and a decent potential for relief. Grade of Recommendation: Weak recommendation based on moderate-quality evidence, 2B. Phlebotonics are a heterogeneous class of drugs used to treat both acute and chronic hemorrhoidal disease. Although their true mechanism of action has not been well established, they are associated with strengthening of blood vessel walls, increasing venous tone and lymphatic drainage, and normalizing capillary permeability. In a Cochrane review of 24 randomized controlled trials (RCTs) enrolling a total of 2334 participants, which compared an intervention using phlebotonics with a control, phlebotonics demonstrated a statistically significant beneficial effect for the outcomes of pruritus (OR = 0.23 (95% CI, 0.07–0.79); p = 0.02), bleeding (OR = 0.12 (95% CI, 0.04–0.37); p = 0.0002), discharge and leakage (OR = 0.12 (95% CI, 0.04–0.42); p = 0.0008), and overall symptom improvement (OR = 15.99 (95% CI, 5.97–42.84); p < 0.00001). Although beneficial, they did not show a statistically significant effect when compared with a control intervention for pain (OR = 0.11 (95% CI, 0.01–1.11); p = 0.06).16 A meta-analysis reviewed 14 RCTs comparing flavonoids (diosmin, micronized purified flavonoid fraction, and rutosides) with placebo or no therapy in patients with symptomatic hemorrhoids (1514 patients). Flavonoids were noted to have a beneficial effect on bleeding, pruritus, and recurrence (RR = 0.53).17 Although topical application of ointments containing anesthetics, steroids, emollients, and/or antiseptics are used commonly, their prolonged use can cause allergic reactions or sensitization, and there is no strong scientific evidence regarding their long-term use. OFFICE TREATMENT 1. Most patients with grade I and II and select patients with grade III internal hemorrhoidal disease who fail medical treatment can be effectively treated with office-based procedures, such as banding, sclerotherapy, and infrared coagulation (IRC). Hemorrhoid banding is typically the most effective option. Grade of Recommendation: Strong recommendation based on high-quality evidence, 1A. The goals of office-based procedures are to alleviate patient symptoms by decreasing the size or vascularity of the hemorrhoidal tissue and to increase the fixation of the hemorrhoidal tissue to the rectal wall to minimize prolapse. These procedures are all relatively well tolerated and cause minimal pain and discomfort. However, patients should understand that they all have a variable recurrence rate and may require repeated applications.18,19 Rubber Band Ligation The most popular and effective treatment is rubber band ligation (RBL), which has been shown to be superior to sclerotherapy and IRC.20 Ligation of the hemorrhoidal tissue results in ischemia and necrosis of the prolapsing mucosa followed by scar fixation to the rectal wall. This quick technique is well tolerated in patients, because the ligature is performed well above the dentate line, where somatic sensitivity is absent. One large case series including 750 consecutive patients with grade II and III hemorrhoids reported a cure rate of 93% and a recurrence rate of 11% after 2 years, which was not influenced by the grade of hemorrhoid.19 The efficacy of RBL in treating grade II and III hemorrhoids was evaluated in an RCT, and after 1 year, 49% of the 176 patients had recurrent hemorrhoidal symptoms, of which the majority were treated with repeat RBL (32% of the cohort required additional procedures, more than half of which were repeat RBL).21 A Cochrane review evaluated the efficacy of RBL with respect to grade of hemorrhoids and found that excisional hemorrhoidectomy was superior to RBL for grade III hemorrhoids (2 trials, 116 patients, RR = 1.23 (95% CI, 1.04–1.45); p = 0.01). However, no significant difference was noticed with grade II hemorrhoids (1 trial, 32 patients, RR = 1.07 (95% CI, 0.94–1.21); p = 0.32). Fewer patients required retreatment after excisional hemorrhoidectomy (3 trials, RR = 0.20 (95% CI, 0.09–0.40); p < 0.00001).22 Although there is limited evidence regarding the safety of RBL in patients on anticoagulation, it is generally considered a contraindication. In 1 large retrospective review of 805 patients undergoing 2114 RBLs, 25.0% of patients on warfarin bled postprocedure compared with 7.5% taking aspirin or nonsteroidal anti-inflammatory drugs. Of note, only 2.9% of patients bled postprocedure when not taking any of these products.23 Sclerotherapy A variety of techniques and sclerosing agents have been described for treating grade I to III internal hemorrhoids. The most commonly used sclerosant agents are 5% phenol in almond or vegetable oil or sodium tetradecyl sulfate, a sclerosant that is approved by the US Food and Drug Administration only for treating small varicose veins of the lower extremities (Sotradecol, Elkins-Sinn, Cherry Hill, NJ). The mechanism of action is fibrosis of the submucosa with subsequent fixation of the hemorrhoidal tissue. Injection is performed into the submucosa at the apex of a hemorrhoidal bundle (0.5–2.0 mL of 1% sodium tetradecyl sulfate or 1.0–3.0 mL of 5% phenol in oil). The injection may also result in mucosal ulceration or necrosis and rare septic complications, such as prostatic abscess and retroperitoneal sepsis.24 Transient bacteremia has been reported in 8% of individuals after sclerotherapy, and antibiotic prophylaxis should be considered for individuals at increased risk.25 There are limited data on the efficacy of sclerotherapy, with 1 recent trial demonstrating only 20% success at 1 year in the treatment of grade III hemorrhoids.26 The results appear to be much better for the treatment of grade I hemorrhoids, with a recent trial evaluating the efficacy of polidocanol, a nonester local anesthetic approved for use by the US Food and Drug Administration, with 88% of patients treated successfully (12-week follow-up).27 Although there are no randomized data to support the use of sclerotherapy in anticoagulated patients, a case-matched series of 37 patients receiving antiplatelet therapy, including aspirin, ticlopidine, clopidogrel, and cilostazol; anticoagulant therapy, including warfarin; or both antiplatelet therapy and anticoagulant therapy, showed no difference in postprocedure bleeding rates.28 Newer agents are being evaluated and used throughout Asia and and have been shown to be more in the treatment of more of hemorrhoids to are not available for use in the United the role of sclerotherapy in the treatment of hemorrhoids will to be the application of infrared resulting in necrosis the This is most commonly used for grade I and II hemorrhoids. Although previous demonstrated rates of with grade III and recent randomized have demonstrated outcomes to The most recent to evaluate for grade I and II internal hemorrhoids demonstrated control of symptoms in of patients at after whereas of patients required a repeat of the of is one must that is a that can after office-based procedures or after anal in pain, or after an office-based anal procedure may be the of and should typically an patient is the most common and more after RBL then other office-based It generally after the procedure and is to be related to the Although the are not well patients who undergo RBL will significant pain because of of the band or the dentate line, which will to be Patients should be counseled regarding these rare HEMORRHOIDS 1. patients with thrombosed external hemorrhoids may from surgical Grade of Recommendation: Weak recommendation based on low-quality evidence, There is a of on external hemorrhoid and that provide of evidence. may be superior to there is no evidence regarding the of of Although most patients treated will of their symptoms, of thrombosed external hemorrhoids may result in more symptom lower of and A by assigned patients into 3 treatment including topical application of and of and of the of the pain on after treatment that hemorrhoid the best pain control, followed by topical application of whereas was the There no difference in symptomatic the at reviewed patients who treatment for external hemorrhoid from to of which were treated Of of the thrombosed hemorrhoid, and the and of the The of patients were treated with and topical and of symptoms bleeding, and/or was in a of 24 for patients compared with in the 1. should typically be offered to patients symptoms result from external hemorrhoids or combined internal and external hemorrhoids with prolapse Grade of Recommendation: Strong recommendation based on high-quality evidence, 1A. of hemorrhoids a very effective for patients who fail or office-based procedures, who have grade III or hemorrhoids, or patients with In a meta-analysis of randomized comparing hemorrhoidectomy with office-based procedures, hemorrhoidectomy was the most effective treatment for patients with grade III hemorrhoids. However, it was associated with increased pain and the or hemorrhoidectomy can be performed with a variety of surgical In a meta-analysis of RCTs comparing hemorrhoidectomy the was associated with pain, and risk of complications, hemorrhoid and were In a meta-analysis of 5 with patients, the use of a was found to be and to cause pain when compared with hemorrhoidectomy with rates of were associated with to pain, and in a meta-analysis of compared with When these 2 were evaluated to in an of patients undergoing hemorrhoidectomy, pain were with no in clinical increased are to the use of each of these modalities for a to a by the submucosa to the dentate line, resulting in a of the anal and of the Although effective for internal prolapsing disease, it not address external hemorrhoids. cohort and trials reported stapled to be associated with pain and when compared with excisional assigned patients, including patients to undergo stapled and patients to undergo excisional surgery. was than excisional hemorrhoidectomy in the and surgical rates were The excisional hemorrhoidectomy group had better than the In the stapled of patients reported that their symptoms had compared with in the excisional hemorrhoidectomy group (OR = (95% CI, p < and this difference was at 24 A Cochrane review demonstrated that patients with stapled were more to have recurrent hemorrhoids in long-term at all of the time compared with who excisional hemorrhoidectomy trials, patients, = (95% CI, p = a higher of patients who reported the symptom of prolapse at all time patients, = (95% CI, p = Patients undergoing were also more to require an additional procedure compared with who excisional hemorrhoidectomy patients, = (95% CI, p = When all of the symptoms were patients undergoing excisional hemorrhoidectomy were more to be trials, patients, = (95% CI, in favor of stapled were in pain, pruritus and fecal of the other clinical showed excisional In review of all surgical techniques for the treatment of hemorrhoids, recurrence of hemorrhoidal symptoms was more common after stapled than after excisional has been associated with bleeding, and at the A review of articles including a total of patients found a rate of with 5 and there were published in the literature of rectal after stapled patients required a with fecal and 1 patient was treated by surgical treatment and there were hemorrhoid ligation an with a to identify each hemorrhoid that is are the of tissue and pain. A has also been described for patients with symptomatic prolapse. In general, using have demonstrated A review evaluating including patients with grade I to hemorrhoids, demonstrated a recurrence rate that and recurrence rate = with the rates for grade hemorrhoids. was required in to of rates were with an overall bleeding rate of and an overall rate of The time from to In a randomized trial comparing RBL with for the treatment of grade II and III hemorrhoids, the recurrence rates at 1 year postprocedure were 49% in the RBL group and in the group = (95% CI, p = The reason for this difference was the number of additional procedures required in the RBL group to alleviate symptoms (32% in the RBL group and in the symptom complications, a used assessment and were patients had more pain in the after was also more and was not found to be compared with RBL in of per of after surgical hemorrhoidectomy are with the most common being postprocedure and most series an 1% and has been reported to 1% and and is the most common reason for of surgical patients to be from an The is higher after and after The risk may be with decreasing of and through use of local 2. Patients undergoing surgical hemorrhoidectomy should use a pain to and a Grade of Recommendation: Strong recommendation based on moderate-quality evidence, 1B. In a review of patients undergoing pain reported after hemorrhoidectomy was of surgical A number of in surgical and management have to this has been shown to and pain after A meta-analysis of trials with patients undergoing excisional hemorrhoidectomy and treated with topical demonstrated significant pain reduction as Patients also to than in the control evaluating surgical also efficacy in pain and for after excisional also to the of and anal The of to excisional hemorrhoidectomy was the risk of developing anal leakage after which in most was RCTs have A after pain to be for after excisional effect including incontinence to was to The use of was evaluated in a recent meta-analysis and found to be no better than placebo in has been evaluated in 2 In the patients undergoing excisional hemorrhoidectomy were assigned to were lower in the group p < patients in the group from to after compared with patients receiving placebo and p < through In patients were assigned to a of with or or on of pain were lower with at each < compared with after surgery. The total was lower for the group compared with the group the to = time to use was for for = of was for compared with for =