![]() One of the first and foremost conservative recommendations is a high-fiber diet. ![]() ![]() Hemorrhoids can receive treatment with both medical and/or surgical interventions depending on their degree of prolapse and whether they are external or internal. They are sensitive to touch, stretch, and temperature due to somatic nerve innervation. External hemorrhoids are covered in anoderm and are below the dentate line. Grade 4 hemorrhoids are chronically prolapsed and cannot undergo manual reduction. Grade 3 hemorrhoids also prolapse with Valsalva but need to be manually reduced. Grade 2 hemorrhoids prolapse with Valsalva but spontaneously reduce. Prominent vessels and no prolapse characterize grade 1 hemorrhoids. They are covered by columnar epithelium and are classified based on the degree of prolapse. Internal hemorrhoids develop above the dentate line and are painless due to their visceral innervation. The anal canal is roughly 4 cm long in adults, with the dentate line marking its midpoint. Several anatomic investigations have confirmed the existence of arteriovenous communications between vessels, which clarifies why hemorrhoidal bleeding is bright red and has the same pH as arterial blood. Microscopically, they have been described as sinusoids because they lack muscle, as do veins. Hemorrhoids are cushions of nonpathological vascular tissue in the anal canal. Surgical procedures primarily include closed, also called Ferguson hemorrhoidectomy, which is the most common technique in the United States, or the open, also called Milligan-Morgan hemorrhoidectomy, used in the United Kingdom and Europe. The most effective treatment for recurrent, symptomatic grade III, or IV hemorrhoids, is surgical excision. Hemorrhoids can have treatment with both medical and surgical interventions depending on their degree of prolapse and whether they are internal or external. External hemorrhoids are asymptomatic in most patients except for thrombosed external hemorrhoids, which cause significant pain due to their innervation by somatic nerves. Patients presenting with symptomatic internal hemorrhoids complain of painless, bright red bleeding, described as streaks of blood in the stool, anal itching, pain, worrisome grape-like tissue prolapse, or a combination of these symptoms. Internal hemorrhoids can be further divided on a scale from I to IV based on the degree of prolapse, which also helps guide the treatment options. The three primary hemorrhoidal columns are in the left lateral, right anterolateral, and right posterolateral positions of the anal canal and can be either internal or external based on their location relative to the dentate line. Instead, the current thought is that hemorrhoids develop due to decay or deterioration of the vascular cushions. The pathophysiology of hemorrhoids is mostly unknown, but one theory states that hemorrhoids develop due to varicose veins in the anal canal however, most healthcare providers reject this idea. ![]() Hemorrhoids are columns of vascular connective tissue within the anal submucosa aiding in maintaining continence and bulk to the anal canal. Some sources estimate the incidence of symptomatic patients in the U.S is 4.4%, with patients between the ages of 45 to 65 years old being the most affected. The overall prevalence is unknown because asymptomatic patients are less likely to seek medical help. Hemorrhoidal disease is a common disorder requiring surgical intervention in approximately 10% of cases.
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