Guide to Hemorrhoids

Our surgeons have expertise in both office and outpatient operating room procedures for the management of hemorrhoids such as injection and coagulation, rubber band ligation, stapled hemorrhoidopexy and excisional hemorrhoidectomy.

Treatment of hemorrhoidal disease is based on symptoms. First and foremost, other possible explanations must be excluded, including malignancy. Therefore colonoscopy or other visualization techniques may first be recommended to exclude such a possibility. If medical management is optimal, that is, you have soft bowel movements without straining and have been compliant about observing recommendations to avoid constipation, your physician may offer several therapies to you. If your internal hemorrhoidal symptoms are more complex, or are associated with external hemorrhoidal symptoms as well, office procedures or surgical removal of the hemorrhoids may be warranted. However, your physician will speak with you and outline alternatives in evaluation and treatment.

Our team is available for second opinion consultations for anyone who wishes to confirm a diagnosis or discuss treatment options.

What are Hemorrhoids

Hemorrhoids are swollen blood vessels in the anorectal area. Although hemorrhoids can be painful, they are usually not serious. There are two types of hemorrhoids: internal and external. This distinction is important, because of the possible symptoms and treatment alternatives. The division is marked anatomically by the dentate line, which embryologically delineates where skin-type structures meet with rectal lining structures. Importantly, there are many nerve endings for pain distal (beyond) to this line, where the external hemorrhoids are, whereas proximal (in front) to this line, there are no pain fibers.

Both types of hemorrhoids can bleed, thrombose (clot), and prolapse. Normally, external hemorrhoids can be uncomfortable and sometimes disabling when they thrombose. Internal hemorrhoidal symptoms have been graded:

  • Grade 1: Bleeding
  • Grade 2: Prolapse, but reduce spontaneously
  • Grade 3: Prolapse, require manual reduction
  • Grade 4: Prolapse, unable to be reduced

Initial evaluation includes a history and physical examination. In the history, your physician will ask you questions regarding your symptoms, your diet, previous therapies and examinations. An anoscopy (3-4 inch scope inserted through your anus) may be performed to localize the problem or to determine if other problems coexist.


Office procedures include injection and coagulation of the hemorrhoids, which results in the shriveling of the hemorrhoids. Rubber band ligation is an alternative highly effective office-based technique that applies a tight rubber ring around the hemorrhoid to strangulate a small amount of tissue. Once the ring cuts through the tissue, the ring and the tissue will fall off. This technique produces a dull ache, because there are no true pain fibers in the area of the ligation. Complications are rare, but can be life-threatening. A range of techniques may be also be used in the operating room to remove the hemorrhoids (excisional hemorrhoidectomy) with a surgical scalpel, an ultrasound based scalpel, suture ligation, or stapling of the lining (stapled hemorrhoidopexy).

Thrombosed external hemorrhoid: This is a complication of a hemorrhoid that may occur in association with a recent change in bowel habits or straining due to increased abdominal effort. It will appear as a localized swelling around the anus, the size of a pea or grape, which may be blue or purple in color, and very tender. Pain is due to the clot itself and due to swelling associated with this process. If you are found to have an acutely thrombosed external hemorrhoid, your physician may offer you a small office procedure to remove the clot. Even without such a procedure, the clot and the swelling will dissipate, although during the first 24-48 hours the pain may be so intense that you may be unable to complete your normal daily activity. A mild analgesic may be prescribed.

Perianal ("around" the anus) care includes the avoidance of constipation, sitz baths (sitting in warm water several times a day and after bowel movements), and good hygiene. Despite the fact that you may have an open wound in a 'dirty' area, infection and abscess formation are rare. External hemorrhoidal disease may produce residual skin tags. These are harmless, but may impair good hygiene.

Next Steps

If you or someone you love is in need of care for a colorectal issue, we’re here to help. Our team is available for consultations, second opinions, and to perform any colorectal procedure, should one be necessary. Call us at (212) 342-1155 or request an appointment online.