Case 8.5 – Internal & External Haemorrhoids

History and Examination for Rectal Bleeding:

History

• Haemorrhoidal protrusion or bleeding - assess nature and severity
• Bleeding severity - may be minimal, appearing only on toilet paper, or it may occasionally be severe enough to cause anaemia
• Bleeding characteristics - usually bright red, coats the stool (rather than being mixed with it)
• Pain assessment - haemorrhoids are usually painless (unless there is thrombosis, ulceration or gangrene)
• Bowel habits and constipation
• Duration and frequency of symptoms
• Associated symptoms (pain, itching, prolapse)
• Past medical history and risk factors

Key Clinical Features

• Bright red blood coating the stool
• Blood on toilet paper
• Usually painless bleeding
• May have associated protrusion

Examination and Classification of Internal Haemorrhoids:

Grading System

In cases of protrusion, the haemorrhoids are graded according to the level of prolapse:

• First degree internal haemorrhoids - do not prolapse; the proctoscope (anoscope) must be used to visualize them
• Second degree internal haemorrhoids - prolapse with defecation and return spontaneously to their anatomic position
• Third degree internal haemorrhoids - prolapse with defecation and require manual reduction
• Fourth degree haemorrhoids - are not reducible

Classification Notes

• There is no classification for external haemorrhoids; they are either present or absent
• Mixed haemorrhoids are a combination of internal and external haemorrhoids

Examination Techniques

• Visual inspection of perianal area
• Digital rectal examination
• Proctoscopy (anoscopy) - essential to visualize first degree haemorrhoids
• Assessment during straining to identify prolapse

Distinguishing Features of Haemorrhoids:

Anatomical Location

• Typical positions - haemorrhoids are usually found in three constant positions: left lateral, right anterior & right posterior
• Internal haemorrhoids - originate above the dentate line
• External haemorrhoids - are located below the level of the dentate line

Pain and Sensation

• Internal haemorrhoids - because the rectal mucosa above the dentate line is relatively insensate, bleeding from internal haemorrhoids is usually painless
• External haemorrhoids - conversely, external haemorrhoids are covered by richly innervated anoderm and usually cause pain when thrombosis occurs

Key Distinguishing Features

Feature	Internal Haemorrhoids	External Haemorrhoids
Location	Above dentate line	Below dentate line
Pain	Usually painless	Painful when thrombosed
Mucosa	Rectal mucosa (insensate)	Anoderm (richly innervated)
Position	Left lateral, right anterior, right posterior	Variable

Classification and Management of Internal Haemorrhoids:

Degree	Definition	Treatment
First	Bulge in the anal canal lumen; does not protrude outside the lumen	Asymptomatic: Take stool bulking agents Avoid constipation Increase water intake Symptomatic: Same as above Rubber band ligation Infra-red coagulation
Second	Protrudes with defaecation; reduces spontaneously	Conservative management (as above) Rubber band ligation
Third	Protrudes with defaecation; must be reduced manually	Selected cases: rubber band ligation Mixed: surgical haemorrhoidectomy
Fourth	Protrudes permanently; incarcerated	Surgical haemorrhoidectomy

Treatment Principles

• Conservative management is first-line for grades 1-2
• Interventional procedures (rubber band ligation, infrared coagulation) for symptomatic grades 1-2 and selected grade 3
• Surgical haemorrhoidectomy reserved for grade 3 (selected cases) and grade 4

External Haemorrhoids - Presentation and Management:

Presentation

• Usually cause few problems in most cases
• Large external haemorrhoids may interfere with perianal hygiene and thus be indirectly associated with pruritus ani
• Thrombosed external haemorrhoids present with acute severe pain due to richly innervated anoderm
• May present as a tender perianal lump
• Swelling and inflammation in the perianal area

Management

• Asymptomatic external haemorrhoids - no treatment required
• Large external haemorrhoids interfering with hygiene - excision may be indicated
• Thrombosed external haemorrhoids:
  • Conservative management with analgesia and stool softeners if presenting after 72 hours
  • Surgical excision if presenting within 72 hours of symptom onset
• Symptomatic relief with topical preparations
• Warm sitz baths

Key Points

• No classification system for external haemorrhoids (present or absent)
• Treatment is based on symptoms rather than degree
• Excision reserved for symptomatic cases affecting quality of life