What is this condition and how is it classified?
How does staging affect management?
This photograph shows prolapsed and thrombosed haemorrhoids with some superficial skin ulceration. Primary haemorrhoids are characteristically located at the 3, 7 and 11 o'clock positions with the patient lying in the lithotomy position and secondary haemorrhoids lie between these three classical positions. They are also classified by degree of prolapse (or stage). First degree haemorrhoids are confined to rectum and do not prolapse out of the anal canal. Second degree haemorrhoids prolapse through the anus on defaecation but reduce spontaneously. Third degree haemorrhoids prolapse and require manual digital reduction whilst fourth degree ones are permanently prolapsed. Treatment options range from conservative dietary advice to surgery depending on the degree.
See below for more detail
The treatment of haemorrhoids is dependent on the degree at presentation. First degree piles may be asymptomatic or present with rectal bleeding and possible faecal soiling. Dietary advice with implementation of a high-fibre diet may be sufficient. In second degree piles the patient is aware of early prolapse. Reduction in the size of the piles can be achieved by a variety of out patient treatments including injection sclerotherapy into the submucosal layer above the dentate line, rubber band ligation via a proctoscope, infra red coagulation and cryotherapy. Once the piles have progressed to third degree then surgical haemorrhoidectomy (sometimes called dissection and ligature or the St Marks operation) is likely to be required. Stapled haemorrhoidectomy is currently under evaluation. Irreducible and thombosed piles may present as an emergency with the patient in severe pain. They may be treated conservatively by analgesia, bed-rest, elevation of the foot of the bed and ice-packs. The piles will often shrink and ultimately reduce back into the anal canal although this may take some days. An alternative treatment is immediate haemorrhoidectomy.