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Hemorrhoids are a common cause of perianal complaints and affect 1-10 million people in North-America and with similar incidence in Europe. Symptomatic hemorrhoids are associated with nutrition, inherited predisposition, retention of feces with or without chronic abuse of laxatives or diarrhea. Increased pressure and shearing force in the anal canal may lead to severe changes in topography with detachment of the hemorrhoids from the internal sphincter and fibromuscular network resulting in bleeding, itching, pain and disordered anorectal function, even incontinence. The significance of hemorrhoids for anal continence (corpus cavernosum) is recognized. In most instances, hemorrhoids are treated conservatively; the surgeon is contacted when conservative measures have failed or complications, e.g., thrombosis, have occurred. 4 degrees prolapsed internal hemorrhoids are the main indication for hemorrhoidectomy: high (Parks) or low (Milligan-Morgan) ligation with excision, closed hemorrhoidectomy (Ferguson) or stapler hemorrhoidectomy. Thrombosed external hemorrhoids are primary treated by incision and secondary by excision. Complications after operative treatment of external thrombosed hemorrhoids are rare. After standard hemorrhoidectomy for internal hemorrhoids approximately 10% may have a complicated follow-up (bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, incontinence); there may be concomitant disease, e.g., perianal cryptoglandular infection, causing complex fistula/abscess, which is associated with an increased risk (30-80%) for complications, e.g., incontinence. Other treatment options, e.g., sphincterotomy, anal stretch, have been accused to cause more complications, e.g., incontinence in 30-50% of cases. However, incontinence is a complex phenomenon; it is evident that an isolated single injury is normally not a sufficient cause, e.g., injury of the internal sphincter. The majority of patients may present with prior obstetric injury, perianal infection or Crohn's disease and other comorbidity. Therefore all systemic and regional disorders, causing incontinence, should be excluded before starting manometric, neurophysiological and sonographic investigations. Variation and overlap in test results, patient-, instrument- or operator-dependent factors ask for cautious interpretation. There is vast evidence that the demonstration of muscle fibers in hemorrhoidectomy specimens is a normal feature. In conclusion, standard hemorrhoidectomy with proper indication is a safe procedure. If complications occur, it is in the interest of the patient and surgeon to perform a thorough investigation.
Abstract: Hemorrhoids are a common cause of
perianal complaints and affect 1-10 million people
in North-America and with similar incidence in
Europe. Symptomatic hemorrhoids are associated
with nutrition, inherited predisposition, retention
of feces with or without chronic abuse of laxatives
or diarrhea. Increased pressure and shearing force
in the anal canal may lead to severe changes in to-
pography with detachment of the hemorrhoids
from the internal sphincter and fibromuscular net-
work resulting in bleeding, itching, pain and dis-
ordered anorectal function, even incontinence.
The significance of hemorrhoids for anal conti-
nence (corpus cavernosum) is recognized. In most
instances, hemorrhoids are treated conservatively;
the surgeon is contacted when conservative meas-
ures have failed or complications, e.g., thrombo-
sis, have occurred. 4° prolapsed internal hemor-
rhoids are the main indication for hemorrhoidec-
tomy: high (Parks) or low (Milligan-Morgan) liga-
tion with excision, closed hemorrhoidectomy
(Ferguson) or stapler hemorrhoidectomy. Throm-
bosed external hemorrhoids are primary treated
by incision and secondary by excision. Complicati-
ons after operative treatment of external throm-
bosed hemorrhoids are rare. After standard he-
morrhoidectomy for internal hemorrhoids ap-
proximately 10% may have a complicated follow-
up (bleeding, fissure, fistula, abscess, stenosis, uri-
nary retention, soiling, incontinence); there may
be concomitant disease, e.g., perianal cryptoglan-
dular infection, causing complex fistula/abscess,
which is associated with an increased risk (30-80%)
for complications, e.g., incontinence. Other treat-
ment options, e.g., sphincterotomy, anal stretch,
have been accused to cause more complications,
e.g., incontinence in 30-50% of cases. However,
incontinence is a complex phenomenon; it is evi-
dent that an isolated single injury is normally not
a sufficient cause, e.g., injury of the internal
sphincter. The majority of patients may present
with prior obstetric injury, perianal infection or
Crohn’s disease and other comorbidity. Therefore
all systemic and regional disorders, causing incon-
tinence, should be excluded before starting mano-
metric, neurophysiological and sonographic inves-
tigations. Variation and overlap in test results, pa-
tient-, instrument- or operator-dependent factors
ask for cautious interpretation. There is vast evi-
dence that the demonstration of muscle fibers in
hemorrhoidectomy specimens is a normal feature.
In conclusion, standard hemorrhoidectomy with
proper indication is a safe procedure. If complica-
tions occur, it is in the interest of the patient and
surgeon to perform a thorough investigation.
Key words: hemorrhoids – hemorrhoidectomy –
fecal incontinence – external thrombosed hemor-
rhoids – anal fistula – complication – anal manom-
etry – endoanal sonography – internal anal
sphincter – ischiorectal abscess
Hemorrhoids affect many human beings in
North-America and Europe. It is estimated that
one to ten million Americans suffer from hemor-
rhoidal complaints per year. The incidence ranges
from 58 % to 86 % (Haas et al. 1983; Dennison et
al. 1988; Johanson and Sonnenberg 1990; Bleday
et al. 1992).
Hemorrhoids are classified into external and
internal hemorrhoids. Internal hemorrhoids are
further subclassified into first, second, third and
fourth degree internal hemorrhoids (Thomson
1981; Hulme-Moir and Bartolo 2001). Thickened
cushions of mucosa and submucosa appear to the
right anterior, right posterior, and left posterior
position with possible variations and secondary
cushions. Hemorrhoids consist of venous plexus
and arterial supply embedded in a stroma of con-
nective tissue, smooth muscle and nerves
(Thomson 1975; Mosley et al. 1980).
The epithelial lining of the anal canal has been
divided into three zones: cutaneous, middle, and
mucosa. The cutaneous zone consists of true skin
and squamous stratified epithelium. The transi-
tion zone from cutaneous to middle zones is
called mucocutaneous junction and contains the
anal crypts. The mucosal zone consists of true co-
lumnar epithelium and continues upward as rec-
tal mucosa. On palpation a depression is felt
between the internal and external sphincter,
which should not be confused with a dip formed
by the mucocutaneous junction. According to
Parks Milligan and others confused the visible de-
pression (the line of anal crypts) with the palpa-
ble groove lower in the anal canal (Parks 1956).
This intersphincteric groove may be misleading
in the diagnosis of sphincter defect (Sangwang
and Solla 1998).
Eur J Med Res (2004) 9: 18-36
I. Holzapfel Publishers 2004
R. G. Holzheimer
University Halle-Wittenberg, Germany
In relation to the anal canal, there are two ana-
tomical spaces that are of clinical importance: the
submucous space, lying between the mucous
membrane and the internal sphincter, including
the internal hemorrhoidal plexus, covered by
glandular rectal epithelium, and the perianal space
which contains the external hemorrhoid plexus
and the subcutaneous external sphincter (Milligan
et al. 1937).
The internal sphincter forms a wall of the
whole anal canal though the subcutaneous external
sphincter may occupy the terminal position.
Fibers of the conjoined longitudinal muscle, which
acts as supportive structure for the venous plexus
and the anal submucosa and mucosa penetrate the
internal and external sphincter forming a fibroelas-
tic network (Thomson 1975; Haas and Fox 1977;
Mosley et al. 1980). The longitudinal muscle is at-
tached to the anal skin and anal margin. Through
the gap between the two sphincter muscles passes
the most medial of the terminating strands of the
longitudinal muscle, which gains firm attachment
to the skin over the anal verge. The groove
between the hemorrhoidal plexuses is caused by
the adherence of a fibromuscular band to the mu-
cosa, which was called mucosal suspensory liga-
ment by Parks (1956). It consists of muscularis mu-
cosae, muscle-fibers from the internal sphincter, fi-
brous tissue from the fascia surrounding the inter-
nal sphincter, gains attachment to the mucosa of
the anal crypts and divides the subepithelial space
into the superior compartment containing the
internal hemorrhoidal plexus and the inferior
compartment, marginal or perianal space which
contains the external hemorrhoidal plexus (Parks
1956). Thomson (1975) noted that this smooth
muscle (corrugator cutis ani, musculus submucosae
ani, mucosal suspensory ligament, musculus canal-
is ani) was always present in normal cadavers and
hemorrhoidectomy specimens. The anatomical de-
scription of the conjoined longitudinal muscle
layer and the musculus canalis ani with its relation
to the sphincter muscles, rectal mucosa suggested a
role in normal defecation and internal sphincter
contraction (Fine and Lawes 1940; Shropshear
1960; Lawson 1974; Thomson 1975; Hansen 1976;
Haas and Fox 1977; Lunniss and Phillips 1992;
Loder et al. 1994). Stelzner (1992) emphasized that
with regard to the anorectal continence we are fo-
cused on the sphincter muscles not recognizing the
importance of the corpus cavernosum and the net-
work of the longitudinal muscle mesh. Stieve re-
ported that the internal sphincter might not com-
pletely close the anal canal (Stieve 1928; Stieve
1930). Stelzner has introduced the term corpus
cavenosum with his description of the arteriove-
nous shunts in the hemorrhoids (Stelzner 1962).
The importance of the cushions for the continence
has been elucidated in further studies and it is now
suggested that the vascular filling is contributing
15 to 20 % to the resting anal pressure (Stelzner et
al. 1966; Thomson 1975; Hansen 1977; Gibbons et
al. 1986; Lestar et al. 1989). This has been support-
ed by the finding that excision of the piles in he-
morrhoidectomy may impair continence to rectal
saline infusion (Read et al. 1982).
The pathogenesis of hemorrhoids is not yet finally
elucidated. It has been suggested by several authors
that there is a genetic link, which would explain
the association between hemorrhoids and hernia
and prolapse of the genitourinary system or vari-
cose veins (Stelzner 1962; Burkitt 1975; Loder et
al. 1994). Environmental factors, e.g., low-fiber
diet, constipation, repeated and prolonged strain-
ing, hard stool, chronic use of laxatives, have been
identified to support the development of hemor-
rhoids (Burkitt 1975; Haas et al. 1984). In fact,
straining associated with constipation, gynecolog-
ical prolapse and prolapse of the anal mucosa with
loose stools, diarrhea or ulcerative colitis can be
found in the patient history (Stern 1964). Chronic
abuse of laxatives has been observed in 22.2% of
males and 76.4% of females prior to hemorrhoidec-
tomy (Kouba 1980). In recent reports it has been
proposed that hemorrhoids are caused by patho-
logic slippage of the normal lining of the anal
canal together with changes in connective tissue,
e.g., loss of organization, muscular hypertrophy,
fragmentation of the muscle and elastin compo-
nents which may be aggravated by stress during
defecation (Gass and Adams 1950; Thomson 1975;
Haas and Fox 1980; Haas et al. 1983; Haas et al.
1984; Loder et al. 1994). Venous stasis, ischemia,
edema, clot formation may be responsible for com-
plications of the hemorrhoidal disease, e.g., super-
ficial ulceration, fissure formation, hemorrhagic
infarction, external thrombosed hemorrhoids
(Dayal and DeLellis 1989; Jongen et al. 2003).
Patients with symptomatic hemorrhoids may
have bleeding, prolapse, pain, itching, mucous dis-
charge, leakage of anal contents, soiling, rectal
dysfunction, incontinence, feeling of a lump and
constipation (Stern 1964; Ganchrow et al. 1971;
Thomson 1994).
The anal cushions resemble erectile tissue contain-
ing large blood spaced fed by arterioles (Thomson
1975). In normal subjects they may help to pre-
serve continence by forming an expansive seal
(Gibbons et al. 1986). Forty % of patients with
hemorrhoids, especially non-prolapsing hemor-
rhoids, complain of obstructed defecation and vig-
orous straining (Hancock 1977; Sun et al. 1990)
leading to increased anal pressure, lower rectal
compliance and more perineal descent (Arabi et
al. 1977; Hiltunen and Matikainen 1985; el-Gendi
and Abdel-Baky 1986; Lin 1989; Sun et al. 1990;
Ho et al. 1995). It has been assumed that the ab-
normal high anal pressures are caused by an in-
creased tonic activity of the internal and external
sphincter (Hancock 1977; Teramoto et al. 1981;
Lane 1982), which may hinder defecation, and
cause expansion of the anal cushions by impairing
venous drainage (Sun et al. 1990). Teramoto dem-
onstrated by biopsies taken from anal sphincters
in patients with hemorrhoids that these were in a
state of increased tonic contraction, which causes
muscle hypertrophy and may contribute to in-
creased resting pressure (Teramoto et al. 1981).
More recently, the anal cushions were rediscov-
ered as main cause for the high resting and residu-
al pressures in the outer canal by demonstrating
abnormally high vascular pressure in anal cush-
ions themselves (Sun et al. 1990). Hancock (1976)
considered ultraslow waves to represent a syn-
chronous contraction of the whole internal
sphincter. Roe et al. (1987) observed that ultra-
slow waves were associated with high pressures
and often a pulse wave was superimposed indicat-
ing the vascularity of the hemorrhoidal tissue.
Ultraslow waves may represent some form of per-
istaltic action in the sphincters by the presence of
hemorrhoids (Roe et al. 1987). During defecation,
when sphincters are relaxed to facilitate expulsion
of stool, dilated anal cushions could cause anal re-
sistance, which could only be overcome by in-
creased abdominal pressure (straining). This pres-
sure may create a shearing force with detrimental
effect on venous drainage of the cushions, connec-
tive tissue supporting the anal lining finally lead-
ing to intermittent or permanent prolapse of hem-
orrhoids and influencing the continence (Hancock
1977; Hancock 1981; Shafik 1984; Gibbons et al.
1986; Sun et al. 1990). The external sphincter in
patients with hemorrhoids may remain in a state
of increased tonic contraction, inducing muscle
hypertrophy; the role of the internal sphincter for
the pressure in the anal canal when a bolus is
present may be overestimated (Teramoto et al.
1981). Especially females with a history of consti-
pation and preg-nancy were recognized to be
prone to develop spontaneous incontinence
(Stelzner 1992). Despite controversy on the occur-
rence of increased resting anal pressure in patients
with symptomatic hemorrhoids (Fantin et al.
2002) it is well accepted that there is distal dis-
placement of anal cushions with loosening and
fragmentation of the subepithelial connective tis-
sue (conjoined longitudinal muscle, musculus can-
alis ani, fibromuscular ligament) with a significant
change of the topography of the anal canal which
may affect continence (Parks 1956; Stelzner 1962;
Thomson 1975; Hansen 1976; Hansen 1977; Haas
et al. 1984; Stelzner 1992; Loder et al. 1994).
For diagnosis of hemorrhoids a detailed history
with local and general examination may be neces-
sary. Inspection and proctoscopy may reveal acute
thrombosed external or internal hemorrhoids;
however, perianal abscess, submucous abscess, and
even ischio-rectal abscess should be ruled out.
Sigmoidoscopy, colonoscopy or further radiologic
examinations (barium enema, MRT) may be nec-
essary in individual cases. (Stern 1964). The
sphincter ani externus and internus can be palpat-
ed well and their functional status checked. The
inferior part of the sphincter ani internus has been
described by Stelzner as “hard as cartilage”
(Stelzner et al. 1966). Sensitivity of the anal canal,
which is also important for continence, is highest
in the lower part (Stelzner 1992).
Evidence-based treatment modalities include injec-
tion sclerotherapy, photocoagulation, cryothera-
py, diathermy, banding, laser, open or closed he-
morrhoidectomy and stapled hemorrhoidectomy
(Holzheimer 2001). The indication for hemor-
rhoidectomy should be based on the patient’s
symptoms and the condition of rectal outlet
(Ferguson and Heaton 1959). Associated anorectal
disease may be present at least in 22 % of patients
(Bleday et al. 1992). Patients with long-standing
hemorrhoids may have impaired anal sphincter
pressures associated with perineal descent and pu-
dendal nerve injury (Hancock 1976; Read et al.
1982; Bruck et al. 1988; Ho et al. 1995). External
sphincters may be hypertrophied probably from
hyperactivity in response to an irritating anal
mass as well as the constant fear of soiling from
discharge associated with piles (Teramoto et al.
1981). Most patients with symptomatic hemor-
rhoids may be treated conservatively (45.2%) or
by rubber band ligation (44.8%) (Rudd 1970;
Bleday et al. 1992). The most common indication
for surgery are persistent grade IV hemorrhoids
after failure of conservative management with the
conventional excision-ligation (Milligan-Morgan)
hemorrhoidectomy being the most common tech-
nique in Britain and Ireland (Beattie et al. 2002),
but the best treatment for hemorrhoids is preven-
tion (Brisinda 2000). Patients seek surgical atten-
tion often after onset of complication or when
medical therapies have failed. Surgical interven-
tion is required when clear signs and significant
discomfort are present (Tajana 1989).
The operation should aim at the removal of the
dilated veins, ligation of the hemorrhoidal arteries
and fixation of the anal mucosa to the underlying
muscle (internus) to prevent prolapse and to oblit-
erate the submucous space (Parks 1956). Ligation
of the hemorrhoidal artery may be done as high li-
gation (Parks 1956) or low ligation (Milligan et al.
1937). Closed hemorrhoidectomy is supposed to
be less painful and may preserve anal sensory
function better and lead to faster wound healing
(Ferguson and Heaton 1959; Khubchandani et al.
1972) but it has a reputation in Europe for dehis-
cence and infection (Turell 1952; Watts et al.
1964). However, Ferguson insisted that complicat-
ions such as abscess or para-anal cellulitis practi-
cally never occur after closed hemorrhoidectomy
(Ferguson and Heaton 1959). In Europe the
Milligan-Morgan procedure is preferred whereas
in the United States the closed hemorrhoidectomy
as described by Ferguson is more popular
(Milligan et al. 1937; Ferguson and Heaton 1959;
Wolf et al. 1979; Arbman et al. 2000). However,
only few studies have compared closed and open
techniques (Gemsenjäger 1989; Ho et al. 1997;
Arbman et al. 2000); nevertheless, both operations
may have an impact on the maximum resting pres-
sure leaving the recto-anal inhibitory reflex un-
changed which would infer that the hemorrhoidal
tissue itself is responsible for the increased pres-
sure (Roe et al. 1987). In most descriptions of the
hemorrhoidectomy technique the dissection of
the mucosal ligament of the internal sphincter
opens up a plane between the superior hemor-
rhoidal plexus and the internal sphincter – the
plane of the M. canalis ani or M. corrugator ani
(Milligan et al. 1937; Parks 1956; Ferguson et al.
1971; Stelzner 1992). Stelzner has emphasized that
only hemorrhoids which have been disconnected
from the rectum and/or sphincter ani internus or
a fibrotic/thrombotic at the anal verge fixated seg-
ment of the hemorrhoids (external hemorrhoid)
may be securely resected (Stelzner 1992). Parks’
observations support this notion: adherent muco-
sa is difficult to rise from the underlying muscle
unless continued prolapse has resulted in attenua-
tion of the mucosal ligament. In third degree piles
the mucosal ligament has disappeared and the
mucosa flaps have to be fixed to the muscle be-
cause otherwise the slipping down of rectal muco-
sa may cause discharge and irritation (Parks 1956).
Some authors have recommended an additional
sphincterotomy for surgical treatment of hemor-
rhoids, although this may be associated with a risk
for incontinence (Tajana 1989; Arbman et al.
2000). Baradnay (1974) stated that the high recur-
rence rate after the Langenbeck (1852) operation,
and the frequent incontinence, stricture and mu-
cosal prolapse after the Whitehead (1887) opera-
tion, has been a stimulus for the surgeons to look
for better procedures (Milligan et al. 1937, Parks
1956; Ferguson and Heaton 1959; Baradnay 1974),
but neither closed nor open techniques are per-
fect. Postoperative pain, a frequent nuisance to
the patient, led to the introduction of the stapler
procedure as described by Longo for the treat-
ment of third and fourth degree hemorrhoids
(Longo 1998; Kohlstadt 1999; Rowsell et al. 2000;
Fazio 2000).
Thrombosed external hemorrhoid, located in the
marginal or perianal space, is probably one of the
most frequently diagnosed anorectal emergencies
and as a result excision is a frequently performed
anorectal operation (Jongen et al. 2003).
Symptomatic isolated thrombosed external hem-
orrhoids may ask for a much higher excision rate
(84 %) than internal disease, which may be due to
the increased occurrence and recurrence of exter-
nal thrombosed hemorrhoids (Bleday 1992).
Although acute thrombosed external hemorrhoids
are usually obvious, according to Stern (1964)
they should be differentiated from perianal ab-
scess, submucous abscess or even ischiorectal ab-
scess. The treatment strategy from that performed
in internal non-thrombosed hemorrhoids differs:
in acute thrombosed hemorrhoids it is not neces-
sary to perform a standard three-position hemor-
rhoidectomy but rather just to remove sympto-
matic tissue (Hayssen et al. 1999; Hulme-Moir and
Bartolo 2001).
Poor results of hemorrhoidectomy have nearly al-
ways been reported by surgeons among cases referred
to them in which the initial treatment was given
elsewhere. Those who have attempted to follow-up
their own cases have all reported satisfactory results
Parks (1965) was quite aware that it is difficult to
evaluate postoperative complications due to flaws
in subjective – there is a group of patients with he-
morrhoidal symptoms who have either weak anal
sphincters or whose muscle relax easily when they
strain is leading to a descent of the perineum and a
shallow anal canal – and objective factors – assess-
ing the results of operations performed elsewhere
may be difficult as one never can be sure what
procedure was carried out (Parks 1965). 13-18 %
of treated patients had preoperative incontinence,
soiling was reported in 82-84 %, bleeding in 95-97
% and prolapse in 79-82 % of patients (Arbman et
al. 2000). Even histological examination may not
be reliable as the fixed tissue lost its elasticity. The
interpretation of the actual topography is finally
left to the attentive surgeon (Stelzner 1992). On
the other hand, surgical hemorrhoidectomy is
known to have an impact on continence – conti-
nence to saline infusion and anal canal pressures
are reduced – which may be due to anal dilatation
(Read et al. 1982; Ho and Tan 1997; Shalaby and
Desoky 2001). Hemorrhoidectomy is the most de-
finitive way of treating prolapsing piles.
Postoperative pain is a major concern, and surgery
itself is not without complications, including not-
ably bleeding and anal stricture (Golighten et al.
1969; Milsom and Mazier 1986; MacRae and
McLeod 1995). Recurrence of hemorrhoids after
hemorrhoidectomy has been observed in 0.5 % to
26 % of cases (Bennett et al. 1963; Tajana 1989;
Konsten and Baeten 2000).
Complications occurring within the first two
postoperative days include urinary retention,
bleeding, soft fecal impaction, and itching. Later
complications include urinary tract infection, sec-
ondary bleeding, wound infection, fissure and in-
continence. Up to 50% of patients complain of
soiling in the early postoperative period (Roe et
al. 1987; Isler 1999).
Emergency surgery, usually performed by junior
doctors, did not result in a higher incontinence
rate when compared to elective operation (4.4 %
versus 5.2 %) (Eu et al. 1994).
Some types of techniques seem to be associated
with a higher complication rate. Four piles he-
morrhoidectomy may have an increased risk of in-
continence when compared to modified radical
hemorrhoidectomy (Seow-Choen and Low 1995).
There is some controversy with regard to addi-
tional sphincterotomy. When anal stretch was
used in the treatment of hemorrhoids 57.3 % of
patients suffered from fecal soiling for ten weeks
postoperatively when compared to 6.4 % of pa-
tients with additional subcutaneous external
sphincterotomy (Asfar et al. 1988; Arbman et al.
2000) whereas Goligher observed impairment of
anal control for 6-12 months postoperatively
(Goligher et al. 1969). It seems fair to say that in
general anal dilatation and lateral sphincterotomy
in combination with open hemorrhoidectomy
may not offer an advantage and carries the risk of
incontinence; however, the interpretation of the
studies remains open as different techniques, e.g.,
open partial sphincterotomy, subcutaneous exter-
nal sphincterotomy, partial lateral internal
sphincterotomy (LIS), were used (Goligher et al.
1965; Mortensen et al. 1987; Asfar et al. 1988;
Bleday et al. 1992; Mathai et al. 1996; Arbman et
al. 2000), and some investigators saw no inconti-
nence in patients treated with excision-ligation
procedure, anal dilatation and open partial sphinc-
terotomy (Arbman et al. 2000). Chung et al.
(2002) found no difference in postoperative com-
plications after harmonic scalpel, bipolar scissors
hemorrhoidectomy or scissors excision (Chung et
al. 2002).
In a survey among the members of the American
Society of Colon and Rectal surgeons (ASCRS)
comparing open and closed techniques inconti-
nence has been observed after both procedures
(0.18 % – 14.6 %) (Wolf et al. 1979). A high inci-
dence of temporary soiling and leakage was pro-
duced by both procedures, with half of the pa-
tients in each group (submucosal hemorrhoidecto-
my; excision/ligation hemorrhoidectomy) affect-
ed (Roe et al. 1987). These figures are supported
by Arbman et al. who reported that six weeks
after closed and open hemorrhoidectomy 28-52 %
had soiling, 9-15 % incontinence. More than one
year after hemorrhoidectomy 24-30 % had soiling
and 8-15 % incontinence (Arbman et al. 2000).
Urinary retention may occur in 4-12 %, early
hemorrhage in 1-3 %, late hemorrhage in 1 %, fis-
sure in 2-4 %, inflammatory complications in 3-6
% of patients treated with the excision/ligation
technique. Pain may be severe in 4-8 %, mild in
55-65 %. Disturbances of continence can be
present even a long time after operation and is
usually due to muscular strains, diarrhea, imper-
fect closure of the anus or change in sphincter
pressure (Baradnay 1974; Tajana 1989; Argov
1999). It became obvious that a definite assessment
of the surgical results cannot be done prior to the
end of a year (Kouba 1980).
The introduction of the closed hemorrhoidecto-
my by Ferguson as opposed to the open technique
by Milligan-Morgan did not eliminate the risk of
delayed bleeding. Obviously, both the classical
open and the closed hemorrhoidectomy tech-
niques are far from optimal: both operations seem
to be followed by protracted convalescence period
and significant prevalence of complications al-
though the fear of infection caused by primary
closure of hemorrhoidectomy incisions is un-
founded (Ganchrow et al. 1971; Buls and
Goldberg 1978; Sayfan 2001).
In the period immediately following operation
not only retention of urine, hemorrhage, occa-
sionally incontinence but also pain may occur
(Parks 1956). Pain sometimes increases a few days
after hemorrhoidectomy and should be differen-
tiated from infection (Carapeti et al. 1998). Watts
et al. (1964) have compared five different forms of
hemorrhoidectomy (excision with high ligation,
excision with low ligation, excision with primary
suture, submucosal excision, excision with clamp
and cautery). Despite the extensive intra-anal
wounds, healing of the mucosal part of the anal
canal proceeded rapidly. There was no difference
in pain following the different types of operation,
with the exception of excision with primary su-
ture, which was more painful (Watts et al. 1964).
Recognition of postoperative pain has been a pow-
erful stimulus to surgeons in introducing various
modifications of technique for this operation
(Watts et al. 1964). Diathermy excision of hemor-
rhoids has not been shown to reduce postopera-
tive pain compared with scissors excision (Seow-
Choen et al. 1992; Andrews et al. 1993).
Stapler hemorrhoidectomy has been compared in
several studies against standard hemorrhoidecto-
my techniques. Data from randomized studies
showed that continence score, anorectal mano-
metric and endoanal ultrasonographic findings
were not different after stapler hemorrhoidecto-
my from those after open hemorrhoidectomy (Ho
et al. 2000). Complications observed were urinary
retention, hemorrhage in up to 50% of cases, anal
fissure, anal stenosis and incontinence (Mehigan et
al. 2000; Ho et al. 2001). The development of
postoperative pain after stapler hemorrhoidecto-
my has been a matter of controversy recently.
Cheetham et al. reported that patients had severe
rectal pain and fecal urgency after stapler hemor-
rhoidectomy (2000), whereas Fantin et al. (2002)
observed only mild rectal pain in 68% and inter-
mittent anal bleeding in 50% of patients. Also oth-
ers have reported less pain and less urinary reten-
tion after stapler operation (Longo 1998;
Kohlstadt et al. 1999; Mehigan et al. 2000; Rowsell
et al. 2000; Cheetham et al. 2001; Ebert and Meyer
2002; Fantin et al. 2002). Ebert and Meyer were
concerned about the high rate of incontinence in
their patients treated with stapler hemorrhoidec-
tomy, although they admitted that these were sub-
jective complaints and preoperative incontinence
was not recorded (Ebert and Meyer 2002). Rarely,
septic complications after stapler hemorrhoidecto-
my were observed (Molloy and Kingsmore 2000).
External hemorrhoids represent distended vascu-
lar tissue distal to the dentate line. They may re-
sult from straining with stools, childbirth, long
car trips or prolonged sitting, constipation or di-
arrhea. 50% of patients treated for acute throm-
bosed external hemorrhoids had previous bleed-
ing/prolapse of hemorrhoids and diarrhea in 54%
of cases (Turell 1952; Sakulsky et al. 1970; Oh
1989). A prior history of hemorrhoids was nearly
always obtained (Stern 1964). Previous anal symp-
toms (wet anus, itching, bleeding at defecation,
prolapsing hemorrhoids) were recorded in 74-88%
of patients (Nieves et al. 1977; Saleeby et al. 1991).
External hemorrhoids are covered by anoderm
and perianal skin richly innervated with somatic
pain fibers, which explains why thrombosis may
cause intensive pain (Zuber 2002). Perianal throm-
bosis results from thrombosis within the rich ex-
ternal venous plexus constituting the most distal
part of the hemorrhoidal mechanism, mostly
caused by stasis and local trauma (Ganchrow et al.
1971; Thomson 1982; Brearly and Brearly 1988;
Oh 1989). Pain will often prevent a full assess-
ment of other local conditions (Stern 1964).
Traditionally, it has been taught, for safety’s sake,
hemorrhoidal crisis should be treated with heat or
ice, bed rest, ointments, analgesics, suppositories,
antibiotics, and in some countries, with prayers to
St. Fiacre, patron saint of proctologists and hemor-
rhoid sufferers” (Nieves et al. 1977). However, a re-
view of the literature has failed to substantiate the
widely held belief that operation at this time car-
ries with it a risk of infection and subsequent por-
tal pyemia (Smith 1967). Usually a simple evacua-
tion of the blood clot through a small incision is
performed (Stern 1964). In up to 70% of cases,
however, a secondary hemorrhoidectomy may be
necessary (Grace and Creed 1975). Hemor-
rhoidectomy is performed through an elliptic or
circumferential incision over the site of the
thrombosis with removal of the entire diseased he-
morrhoidal plexus. Infection after suture closure
is rare secondary to the rich vascular network in
the anal area (Turell 1952; Sakulsky et al. 1970;
Mazier 1973; Hansen and Jorgensen 1975; Grosz
1990; Zuber 2002). Possible complications include
bleeding, excessive scarring, stenosis, fissure and
fistula – incontinence has not been reported as
complication after hemorrhoidectomy of external
thrombosed hemorrhoids (Blessing et al. 1992;
Zuber 2002). Infectious complications of the exci-
sion procedure may relate to unrecognized infec-
tious processes, such as perianal abscess (Zuber
2002; Jongen et al. 2003). Ulceration of the overly-
ing mucosa and not the presence of thrombosis
seemed to be the determinating factor in degree of
inflammatory change. By histological examination
of a segment of the subcutaneous portion of the
external sphincter it has been demonstrated that
thrombosis did not increase the occurrence of
postoperative infection (Laurence and Murray
1962). In conclusion, thrombosed external hemor-
rhoid can be safely performed as outpatient proce-
dure with a low complication rate (Jongen et al.
2003). (Table I)
Fecal incontinence is said to affect at least 2 % of
the adults in the United States (Nelson et al.
1995). The prevalence may be much higher in spe-
cific groups, e.g., multiple sclerosis (51 %), irrita-
ble bowel syndrome (20 %) and diabetes (20 %)
(Feldman and Schiller 1983; Okamoto et al. 1983;
Drossman et al. 1986; Hinds et al. 1990; Harari et
al. 1997; Krogh et al. 1997; Menter et al. 1997).
However, “reluctance to disclose incontinence is
recognized to be an impediment to obtain accurate
estimates of the prevalence of fecal incontinence;
only one-third of individuals with fecal inconti-
nence have discussed this with a physician
(Johanson and Lafferty 1996). The majority of pa-
tients seen in specialized units have incontinence
resulting from trauma, especially obstetrical inju-
ry, from a cryptogenic abscess/fistula, or from a
sphincter disruption due to Crohn’s disease
(Kodner 1990).
Despite the definition of incontinence – recurrent
uncontrolled passage of fecal material for at least
one month – the difficulty has been recognized to
articulate a definition of fecal incontinence that re-
liably separates health from disease (Whitehead et
al. 1999; Whitehead et al. 2001). There may be dif-
ferent forms of incontinence which may be asso-
ciated with specific pathology: passive inconti-
Table I. Complications after surgical treatment of thrombosed hemorrhoids.
Author Patients Type of Operation Fecal Fistula Stenosis Hemorrhage Infection Ulcer Incontinence
hemorrhoid impaction stricture fissure
Laurence and 12 Prolapsed Dissection and Yes No Yes No No No No
Murray 1962 ligation; White-
Tinckler and 39 External Excision No No 3 No No No No
Baratham 1964 prolapsed
Smith 1967 15 Internal St. Marks No No No No No No No
Howard and 25 External Whitehead No No No No No No No
Pingree 1968
Sakulsky et al. 50 Mostly Excision No No No 1 No 1 No
1970 external
Ganchrow A) 100 A) 87 Ferguson No No 1 3 No No No
et al. 1971 B) 30 external
B) 23
Hansen and 25 Prolapsed Milligan- Morgan No No 1 2 No No No
Jorgensen 1975
Nieves et al. 85 Prolapsed St. Marks No No No 1 No 1 No
Saleeby et al. 25 Thrombosed Closed hemor- No No No 1 No No No
1991 or gangrenous rhoidectomy
Jongen et al. 340 External Excision No 7 (2.1%) No 1 (0.3%) See fistula No No
nence (unwanted stool without patient awareness),
urge incontinence (unwanted stool despite active
attempts to inhibit defecation), post-defecation
soiling (stool postvoiding with normal conti-
nence), nocturnal fecal incontinence or inconti-
nence associated with increased bowel frequency;
80% of patients with rectal prolapse report some
degree of incontinence (Talley et al. 1992; Engel et
al. 1995; Buchanan et al. 2001).
Fecal continence is maintained by the integrated ac-
tion of anal sphincteric function, the puborectalis, the
levator plate, and intact sensory pathways. It is de-
pendent on rectal reservoir function, colonic motil-
ity, the volume and consistency of stool, anorectal
sensation, the anorectal angle, normal resting anal
tone and resistance to opening. As continence depends
on several factors, some mechanisms may be able to
compensate and maintain clinical continence when
one element is abnormal. Therefore, objective knowl-
edge of the continence state and of the function of all
components is fundamental to an adequate estimate
of the clinical situation”. In view of the heterogene-
ous etiology of anal incontinence, a uniform defect
in anorectal function should not be expected.
(Felt-Bersma et al. 1990; Felt-Bersma et al. 1992;
Penninckx et al. 1992; Mavrantonis and Wexner
1998; Francombe et al. 2001; Whitehead et al.
2001). True fecal incontinence must be distin-
guished from soiling, which may be caused by def-
ormation of the anal canal, fecal mass in the rec-
tum, mucosal prolapse, and from urgency – pa-
tients are unable to withhold the stool -, which
may be related to impaired rectal compliance due
to inflammatory disease of the rectum.
Incontinence may be due to a sensory loss in the
anal canal, which is characterized by the passage of
feces without the patient being aware of it, as in
rectal prolapse and in patients with neuropathic
incontinence or diabetes (Felt-Bersma et al. 1989;
Mavrantonnis and Wexner 1998). Incontinence
may be associated with perineal descent or de-
scending perineum syndrome which occurs more
often in women, not only because of obstetric in-
jury, but also because of the higher incidence of
straining during defecation, constipation, and out-
let obstruction (Moore-Gillon 1984; Pinho et al.
1990). A thorough history, which includes the pos-
sibility of steatorrhea, neurologic information, ob-
stetric and gynecological surgical history in female
patients, all previous operations upon the anus,
rectum, colon and operations for fistulae and hem-
orrhoids is mandatory (Mavrantonis and Wexner
1998). Causes of incontinence could be simple
structural defects, weak sphincters, idiopathic in-
continence, rectal prolapse, diabetes mellitus, pro-
gressive systemic sclerosis, multiple sclerosis, de-
scending perineum syndrome, perianal infection
(Penninckx et al. 1992; Vaizey et al. 1998). The
cause of incontinence may be classified according
to functional aspects, sphincter weakness, sensory
loss (Whitehead et al. 2001), sphincter complex,
neurological disorders, sensory, alterations of
compliance, congenital, psychological, and miscel-
laneous disorders (Francombe et al. 2001) or trau-
ma, congenital, myopathy, neurological, colorectal
disease, and miscellaneous disorders (Buchanan et
al. 2001). Whitehead et al. (2001) stated that diar-
rhea and constipation are the most common cause
of incontinence. Several compounds may decrease
the anal basal pressure, which may affect conti-
nence, e.g., diltiazem, ketanserin, encephalin, glu-
cagon, somatostatin (Pennickx et al. 1992;
Carapeti et al. 1999; Whitehead et al. 2001). (Table
Before specific investigations are performed, all in-
testinal and systemic disorders must be excluded as
causative factors (Mavrantonis and Wexner 1998).
Due to the multifactorial and complex etiology
the investigation should include anorectal manom-
etry, electromyography, pudendal nerve terminal
Table II. Common causes for fecal incontinence.
Fecal impaction Pelvic floor dyssynergia, drug-side effect, idiopathic, spinal cord injury
Diarrhea Irritable bowel syndrome, infections, metabolic diseases
Cognitive/psychological Dementia, psychosis, willful soiling
Sphincter injury Obstetrical trauma, motor vehicle accident, foreign body trauma, complex fistula
and/or abscess, fistula surgery, hemorrhoidectomy
Pudendal nerve injury Obstetrical trauma, diabetic neuropathy, multiple sclerosis, idiopathic, straining
CNS injury Spina bifida, spinal cord injury, cerebrovascular accident, multiple sclerosis
Sensory loss Diabetic neuropathy, spinal cord injury, multiple sclerosis, surgery
Congenital Hirschsprungs disease, atresia, spina bifida
Colorectal disease Rectal prolapse, rectocele, hemorrhoids, tumors, inflammatory bowel disease
Miscellaneous Laxative abuse, constipation, straining, drugs decreasing anal pressure
Myopathy Primary internal sphincter degeneration, systemic sclerosis
Modified according to Buchanan et al. 2001, Francombe et al. 2001, Whitehead et al. 2001
motor latency, cinedefecography, and anal ultra-
sound. While some authors reported that an expe-
rienced colorectal surgeon is capable of assessing
the resting and squeeze pressures with physical ex-
aminations, others disagree. To make things even
more difficult, the usefulness and practicality of
anorectal neurophysiologic evaluation is a matter
of controversy (Hallan et al. 1989; Wexner et al.
1991; Buchanan et al. 2001). The investigation nor-
mally starts with perianal inspection, which may
reveal scarring from previous surgery, childbirth
damage or episiotomy, hemorrhoids, skin tags or
rectal prolapse, and digital rectal examination for
assessment of anal sphincter tone, impaction, ab-
normalities of stool. Proctosigmoidoscopy is man-
datory to view mucosal abnormality, hemor-
rhoids, fissure, or fistula (Hallan et al. 1989;
Buchanan et al. 2001).
Anorectal manometry is most commonly used to
assess anal sphincter function. Maximum basal
pressure (MBP) was thought for measurement of
the internal sphincter and maximum squeeze pres-
sure (MSP) for evaluation of the external sphincter
(Felt-Bersma et al. 1990). Early study results falsely
gave the impression that the maximum basal pres-
sure is generated for 85 % by the internal sphincter
and for 15 % by the external sphincter (Frenckner
and von Euler 1975). This, however, is no longer
accepted as more recent studies came up with dif-
ferent figures: the MBP is generated for 30 % by
the external sphincter, for 55 % by the internal
sphincter and for 15 % by expansion of the hemor-
rhoidal plexus (Lestar et al. 1989; Felt-Bersma et
al. 1992). Furthermore, the anal manometry may
be influenced by sex, age, prolapsing or non-pro-
lapsing hemorrhoids, rectocele or rectal tumor
presence and repair (Loening-Baucke and Anuras
1985; McHugh and Diamond 1987; Arnold et al.
1990; Felt-Bersma et al. 1990; Sun et al. 1990; Keck
et al. 1995; Ho et al. 1998). “There is no accepted
standardized method of performing or interpreting
this test, thus comparison of data between institutions
has been problematic” (Mavrantonis and Wexner
1998). This and the limited value of anal manome-
try in patients with soiling were repeatedly dem-
onstrated (Felt-Bersma et al. 1989; Diamant et al.
1999). Several studies have analyzed differences
between incontinent and continent patients with
basic anorectal function investigations including
anal manometry, rectal capacity, and the saline-in-
fusion test with controversial results (Read et al.
1979; Read et al. 1984; Felt-Bersma et al. 1988). In
a more recent study Felt-Bersma et al. found no
significant difference in MBP between incontinent
patients and normal controls. Differentiation
between incontinent and continent patients was
not possible with a single test (anal manometry,
rectal capacity, saline-infusion), because there was
complete overlap. “Therefore, in the individual pa-
tient, an abnormal result in one test must be inter-
preted with caution.” (Felt-Bersma et al. 1990). The
saline-infusion test has been developed for demon-
stration of fluid incontinence (Read et al. 1979),
but Felt-Bersma et al. (1990) found no absolute dis-
crimination between incontinent and continent
patients, even when corrected for stool consisten-
cy. Rectal capacity may be influenced by concomi-
tant diseases, e.g., proctitis, Crohn’s disease
(Buchman et al. 1980). Anal sensation has been rec-
ognized as important factor for the continence
(Read et al. 1982; Read and Read 1982). If impaired
it may indicate neurological or postsurgical nerve
impairment (Miller et al. 1989; Kamm and
Lennard-Jones 1990). However, both methods,
anal manometry and determination of anal sensa-
tion, are largely dependent on the patient’s coop-
eration (Read et al. 1982; Felt-Bersma et al. 1990)
and on the absence of certain compounds which
are known to influence anal pressure, e.g., diltia-
zem, etc. (Penninckx et al. 1992) or lignocaine.
Lignocaine is known to double the electrosensitiv-
ity threshold (Roe et al. 1987). The rectoanal in-
hibitory reflex has been proposed as a measure of
the internal sphincter function, but the interpreta-
tion of levels in continent and incontinent patients
is difficult (Buchanan et al. 2001; Zbar et al. 2001).
Pudendal nerve terminal motor latency (PNTML)
is often used to provide additional information on
the innervation of the external anal sphincter.
While some authors report it may reveal unsus-
pected neuropathy in traumatic fecal incontinence
or correlate with outcome from sphincteroplasty
(Felt-Bersma et al. 1992; Engel et al. 1994; Ternent
et al. 1997), the test has been criticized by others
for its lack of sensitivity and specificity (Laurberg
et al. 1988; Wexner et al. 1991; Vernava et al. 1993;
Cheong et al. 1995; Ho and Goh 1995; Gilliland et
al. 1998; Buchanan et al. 2001).
Anal ultrasonography may be used for mapping
internal and external sphincter defects (Yang et al.
1993). Different structures of the upper part, mida-
nal canal or lower part may be identified
(Mavrantonis and Wexner 1998). It is primarily
used for identifying morphologic anomalies
(Whitehead et al. 2001). Interpretation of the ultra-
sonographic investigation may be difficult after
hemorrhoidectomy: Ho et al. (2001) demonstrated
new internal sphincter defects after hemorrhoidec-
tomy, but none of the patients had symptoms of
incontinence. “It is conceded that operator dependen-
cy and possible false identification of anal sphincter
injury at endoanal ultra-sonography is possible” (Ho
et al. 2001). Variability in manometric measure-
ment (Ho et al. 2001) and the use of a 7 MHz
probe instead of a 10 MHz probe (Buchanan et al.
2001) will make the job more difficult.
Unfortunately magnetic resonance imaging, which
is complimentary to endoanal ultrasonography,
has shown lower inter-observer reproducibility for
detecting sphincter defects (Buchanan et al. 2001;
Malouf et al. 2001). Evacuation proctography (de-
fecography) is not of established value in patients
with fecal incontinence (Diamant et al. 1999). In
conclusion, “although anorectal investigations are in
widespread use, their clinical value has sometimes
been doubted” and results of tests should be inter-
preted with caution (Buchanan et al. 2001).
The majority of patients referred to a colorectal
clinic may have incontinence as a result of obstet-
ric injury to the sphincter complex (uncontrolled
second stage delivery, epidural anesthesia, instru-
mental delivery, episiotomy) or as results of pro-
longed labor with damage to the innervation (Nn.
Levatorii, Ganglion pelvinum, Nn. Pudendales)
(Snooks et al. 1985; Stelzner 1991; Sultan et al.
1993; Sultan et al. 1994; Kamm 1994; Poen et al.
1998; Sultan et al. 1998). Occult injuries to the
sphincter are more common than previous thought
and may present many years later (Sultan et al.
1998; Francombe et al. 2001). The occult denerva-
tion of the pudendal innervation is a gradually pro-
gressive phenomenon in that functional effects of
the original injury together with other factors, e.g.,
abnormal straining patterns of defecation with pel-
vic floor descent, are leading to stretch-induced
damage to the pelvic floor during defecation (Parks
et al. 1977; Snooks et al. 1984; Swash et al. 1985;
Snooks et al. 1985b; Snooks et al. 1986; Snooks et
al. 1990). There may be extensive reinervation,
which may explain why in some patients the exter-
nal sphincter seems to be intact despite obstetric
trauma in the past (Wunderlich and Swash 1983).
Childbirth causing damage to the pelvic floor in-
nervation is considered to be a precursor of stress
incontinence (Snooks et al. 1986). After first vagi-
nal delivery endoanal ultrasonography has demon-
strated sphincter defects in 30 % of women (Sultan
et al. 1993). In a study by Jacobs et al. (1990) 19 %
were incontinent without signs of obstetric injury
(Jacobs et al. 1990). This has been supposed to be
an early manifestation of idiopathic (neurogenic)
incontinence, which has been associated with pro-
longed or difficult labor (Neill et al. 1981; Kiff and
Swash 1984). There is evidence gained in recent
studies that 25% of primiparous women and about
33% of multiparous women with a history of vagi-
nal delivery have an anal sphincter defect. The
probability that postpartum fecal incontinence is
associated with an anal sphincter defect is 76.8-82.8
% (Oberwalder et al. 2003).
Many incontinent patients were women with
chronic constipation and a descending perineum.
Incontinence is believed to be caused by chronic
stretch injury of the pudendal nerve and the sacral
branches causing a low anal pressure and an ob-
tuse puborectalis angle (Neill et al. 1981; Bartolo
et al. 1983; Read et al. 1984; Felt-Bersma et al.
1990). Anorectal incontinence due to sphincter
denervation has been demonstrated in patients
with rectal prolapse and fecal impaction (Parks et
al. 1977). Stelzner (1991) has seen an association of
the abuse of laxatives causing toxic damage to the
innervation of the bowel and the consecutive in-
In patients with neurological disease other factors
than childbirth need to be identified, e.g., side ef-
fects of drugs or coexistent behavioral disorders
(Hinds et al. 1990). Fecal incontinence may be ob-
served in patients with multiple sclerosis (50%),
spinal injury (61%), spina bifida (90%), or in pa-
tients with long-standing neuropathy secondary to
diabetes mellitus (Hinds et al. 1990; Malone et al.
1994; Glickman and Kamm 1996). Isolated degen-
eration of the smooth muscle of the internal anal
sphincter may affect both men and women often
in the middle age and is a common cause of soiling
(Vaizey et al. 1997). The resting anal pressure is
usually low and endosonography shows a thin and
fibrotic internal sphincter (Francombe et al. 2001).
Degeneration and fibrosis of the internal anal
sphincter and sensory receptors, leading to passive
fecal incontinence may occur in patients with pro-
gressive systemic sclerosis, idiopathic intestinal
pseudoobstruction and diarrhea may aggravate the
clinical situation (Engel et al. 1994). Incontinence
is seen in patients treated for anal atresia or
Hirschsprung’s disease (Catto-Smith et al. 1995;
Mulder et al. 1995; Hassink et al. 1996). Sphincter
function may also be impaired by radiation injury
(Varma et al. 1985; Varma et al. 1986).
Manual dilatation (Lord procedure) for treatment
of hemorrhoids has not gained widespread accep-
tance since it relies on uncontrolled damage to the
anal sphincter with high incontinence rates (20%
and more) at long-term follow-up (Lord 1969;
MacIntyre and Balfour 1977; Buls and Goldberg
1978; Konsten and Baeten 2000). Fecal inconti-
nence after sphincterotomy may range from 1% to
5%, but 35% of patients may have a lack of control
for flatus and 22% complain of soiling (Buls and
Goldberg 1978; Khubchandani and Reed 1989;
Lund and Scholefield 1996). However, others have
performed sphincterotomy without observing any
case of incontinence (Bleday et al. 1992). Arbman
et al. (2000) used anal dilatation in the Milligan-
Morgan group, but they found no patient with
fecal incontinence after six weeks of follow-up.
Anal abscess and fistula are parts of a spectrum of
the same disease process (Eisenhammer 1954). The
incidence for men has been estimated to be 12.3
per 100.000 and for women 5.6 per 100.000 (Sainio
1984). Anorectal suppuration is usually caused by
cryptoglandular infection. The anal glands, arising
at the level of the crypts, penetrate through the
internal sphincter muscle into the transphincteric
plane (Johnson 1914; Morgan and Thomson 1956;
Shropshear 1960; Schouten and van Vroonhoven
1991). Anal fistula is caused by infected anal glands
in the vast majority of cases (Eisenhammer 1956;
Eisenhammer 1961; Parks 1963). Anal abscess or
fistula may be idiopathic or non-specific. Specific
causes of anorectal sepsis include Crohn’s disease,
tuberculosis, actinomycosis, various malignancies,
gut duplication, foreign bodies, as well as intraab-
dominal or pelvic disease (Seow-Choen and
Nicholls 1992). The site of the internal opening is
relevant for the development of incontinence as is
the type of fistula (high or complex fistula)
(Milligan and Morgan 1934; Belliveau et al. 1983;
Garcia-Aguilar et al. 1996). Most of the ducts have
their orifices in the posterior portion of the anal
canal, which may explain the predominance of
posterior anal fistulae (6 O’clock in lithotomy po-
sition) (Morgan 1936; Burke et al. 1951; Kuster
1965; Cirocco and Reilly 1992). Intersphincteric,
transsphincteric and extrasphincteric fistula were
identified by Stelzner (1959). The most widely
used system of classification is that of Parks: inter-
sphincteric, transsphincteric, suprasphincteric and
extrasphincteric fistula (Parks et al. 1976). The
prevalence of supralevator fistulous abscess varies
from 2-22 % (Eisenhammer 1966; Bevans et al.
1973; Parks et al. 1976; Hanley 1978; Read and
Abcarian 1979; Prasad et al. 1981; Terranova et al.
1989), the prevalence of infralevator or ischiorectal
abscess ranges from 9-38% (Hamilton 1975; Hanley
et al. 1976; Parks and Stitz 1976; Aluwihare 1983;
Ustynoski et al. 1990). Ischiorectal abscess, which
is the second most common anatomic site, is prone
to cause incontinence (Cox et al. 1997). The esti-
mated amount of internal sphincter involved by
the fistula has been identified as an independent
factor for the development of incontinence by
multivariate analysis (Garcia-Aguilar et al. 1996).
Soiling (20.6%) and incontinence (21.8 %) was
present already in one fifth of patients before sur-
gical treat-ment (Schouten and van Vroohoven
1991) and they may have already a poor resting
tone and/or voluntary contraction before opera-
tion, which indicates an already compromised
internal or external anal sphincter function
(Pescatori et al. 1989). Affected patients may have
quite subtle signs despite the development of mas-
sive anorectal suppuration (Seow-Choen and
Nicholls 1992). Problematic fistula and/or abscess-
es may be missed or misdiagnosed even in special-
ized units. Endoanal ultrasonography was not con-
sidered to be as useful as digital examination
(Seow-Choen and Phillips 1991). Management of
anal fistula may be done by classical laying open
(fistulotomy), by excision (fistulectomy) or by in-
cision and drainage. Several studies have shown
continence disturbance in 44 to 67 % of patients
(Parks and Stitz 1976; Hanley 1978; Oh 1983;
Ramanujam et al. 1983; Culp 1984; Kuypers 1984;
Aguilar et al. 1985; Mann and Clifton 1985;
Parkash et al. 1985; Christensen et al. 1986; Wedell
et al. 1987; Reznick and Bailey 1988; Shemesh et al.
1988; Thomson and Ross 1989; Kennedy and
Zegarra 1990; Ustynoski et al. 1990; Schouten et al.
1991; Williams et al. 1991; Seow-Choen and
Nicholls 1992; Kodner et al. 1993; Matos et al.
1993; Pearl et al. 1993; Lunniss et al. 1994; van Tets
and Kuijpers 1994; Graf et al. 1995; Garcia-Aguilar
et al. 1996; Ozuner et al. 1996; Golup et al. 1997;
Hamalainen and Sainio 1997; Ho et al. 1997;
Garcia-Aquilar et al. 2000; Gustafsson and Graf
2002). Early studies have demonstrated a higher in-
cidence of complications with ischiorectal and
intersphincteric abscesses (Chrabot et al. 1983;
Ramanujam et al. 1984; Vasilevsky and Gordon
1984). Major incontinence will follow with drain-
age of transsphincteric fistula with translevator su-
pralevator extension (Parks et al. 1976). Women
are particularly prone to sphincter damage during
surgery for anal fistula (Goldberg 1976; Seow-
Choen and Nicholls 1992). In a more recent study
incontinence was associated with female sex, high
anal fistula, type of surgery, and previous fistula
surgery. “Surgical treatment of fistula-in-ano is asso-
ciated with a significant risk of recurrence and a high
risk of incontinence“(Garcia-Aguilar et al. 1996).
Certain types of fistula may be associated with an
even higher rate of incontinence: transphincteric
54%, suprasphincteric 80%, extrasphincteric 83%
(Garcia-Aguilar et al. 1996). In certain cases it may
be difficult to find the internal openings and the
production of false openings or passages may result
in complex supralevator or infralevator abscesses
(Kratzer 1950; Scoma et al. 1974; Lockart-
Mummery 1975; Hanley 1978; Hanley 1979; Fazio
1987) enbloc resection of the scarred tissue may
cause incontinence (Stelzner 1992). In conclusion,
surgical treatment of fistula-in-ano frequently re-
sults in postoperative incontinence (Garcia-Aguilar
et al. 2000). Even a simple division of an acceptable
portion of the sphincter muscle in low anal fistula
may cause varying degrees of impairment of anal
control (Sainio and Husa 1985; Shoulder 1986).
The risk for incontinence after treatment of ischio-
rectal abscess is higher than after perianal abscess
(Ho et al. 1997). The higher risk of incontinence
after fistula surgery in female patients is probably
attributable in part to partial anal disruption
and/or traction injury to the pudendal nerve dur-
ing vaginal delivery (Garcia-Aguilar et al. 1996).
Hemorrhoidectomy is not generally regarded as
cause of incontinence, but may be a predisposing
factor when the patient has diarrhea (Read et al.
1979; Read et al. 1982). The evaluation is compli-
cated by preexisting comorbidity. Bennett report-
ed that 63% of patients with symptomatic hemor-
rhoids admitted that they have experienced peri-
anal trouble for more than five years before opera-
tion. 86% complained of pain and discomfort prior
to the hemorrhoidectomy (Bennett et al. 1963).
The details of studies on the incidence of inconti-
nence after hemorrhoidectomy are often unclear.
Read has reported an incidence of less than 10 % of
frank incontinence following hemorrhoidectomy
(Read et al. 1982). Bennett is often quoted to re-
port an incidence of 26% of incontinence after he-
morrhoidectomy. However, he indicates that these
were minor defects of anal control and “certainly
do not amount to frank incontinence” (Bennett et al.
1963). Minor defects in anal control do also occur
in normal people, according to Bennett: 10% expe-
rience inadvertent passage of flatus, 3% occasional
unexpected leakage of feces and 2% frequent soil-
ing. He concluded, that as none of the sphincters
are divided in a standard hemorrhoidectomy –
though the possibility of slight inadvertent damage
to superficial layers of the internal sphincter can-
not be entirely excluded – it might be assumed that
the functional imperfections are related to removal
of sensitive anal skin (Duthie and Gairus 1960;
Bennett et al. 1963). “Whether an insensitive anal-
canal scar, weakened sphincter action, or yet uneluci-
dated factors are responsible, it is apparent that
minor imperfections of continence do sometimes
occur after hemorrhoidectomy as well as after other
anorectal operations” (Bennett et al. 1963). The true
incidence of symptomatic soiling after hemorrhoi-
dectomy is unknown which may be due to no or
short follow-up (Bennett et al. 1963; Zbar et al.
2001). Patients have been reported to present with
symptoms of incontinence after hemorrhoidecto-
my 11 months (inter-quartile range 8-16 months)
after hemorrhoidectomy (Zbar et al. 2001). Mano-
metry or sphincter morphology has been studied
only rarely in incontinent patients before and/or
after hemorrhoidectomy and results are conflict-
ing (Read et al. 1992; Abbasakoor et al. 1998; Zbar
et al. 2001). It is well recognized that patients with
long-standing hemorrhoids can have impaired anal
sphincter pressures at rest before surgery (Bruck et
al. 1988; Ho et al. 1995; Zbar et al. 2001) and after
hemorrhoidectomy (Ho and Tan 1997). Several
other factors may influence anal pressure. The
function of the internal anal sphincter may be al-
tered by endoanal retraction during hemorrhoi-
dectomy (Zbar et al. 2001). Increased sphincter
tone is maintained by the presence of hemor-
rhoids, possibly because of reflex tonic contrac-
tion of the internal and external anal sphincter
caused by prolonged stimulation of the anal canal
(Hancock and Smith 1975; Hancock 1976;
Teramoto et al. 1981; Read et al. 1982). The fact
that postoperative squeeze pressures were lower in
patients who soiled after hemorrhoidectomy com-
pared to those who did not suggests that conscious
contraction of the external sphincter may be of
importance in preventing leakage through a dis-
torted anal canal (Read et al. 1982). Hemorrhoi-
dectomy is known to result in the abolition of
ultra-slow waves together with a reduction in basal
and squeeze pressures. An association was found
between soiling following surgery and abnormally
low postoperative squeeze pressure (Read et al.
1982), but manometry failed to correlate with clin-
ical function after operation (Melange et al. 1992).
It also has been stated that morphologic assess-
ment of anal sphincters after surgery may not be
helpful for assessment. “The causes of incontinence
after these types of surgery (lateral sphincterotomy, he-
morrhoidectomy) are probably multifactorial and do
not seem to rely entirely on the presence either of an
occult preexisting sphincter injury or an advertent
intraoperative sphincter injury”(Zbar et al. 2001),
although it has been conceded that individual
patients’ variations in the length and tone of the
anal sphincter, preexisting sphincter injuries unde-
tected by diagnostic modalities and differences in
other anatomic and functional elements may con-
tribute to anal incontinence (Garcia-Aguilar 2001).
Continence is a more complex phenomenon than
mere preexisting or inadvertent intraoperative
sphincter injury. This of course has considerable me-
diolegal significance” (Zbar et al. 2001).
Internal sphincter defect does not necessarily lead
to a state of incontinence. There may be transient
incontinence and/or internal sphincter fragmenta-
tion found on endoanal ultrasound 6-8 weeks after
operation, which may not be present at later con-
trols (Ho et al. 2000). Internal anal sphincter de-
fects seen on the endoanal ultrasound are not nec-
essarily associated with clinical incontinence (Ho
et al. 2000; Brown et al. 2001; Ho et al. 2001).
Complete fecal incontinence does not usually
occur with internal sphincterotomy (Mavrantonis
and Wexner 1998); it is the interaction between
the internal anal sphincter and anal cushions,
which is essential for perfect anal control
(Sanwang and Solla 1998). The anatomic topogra-
phy may also be relevant for the interpretation of
a possible sphincter injury: while internal hemor-
rhoids are in close contact with the internal
sphincter, the external thrombosed hemorrhoid is
located more distally in the anal canal and sphinc-
ter injury does occur less likely, actually there is
none reported in the literature “The pathologist
can tell by looking at the lining of protruding hemor-
rhoids, if they are internal (mucosa lining) or exter-
nal (anoderm)” (Haas et al. 1984).
Smooth muscle fibers are normally present in nor-
mal hemorrhoids (Haas et al. 1984). Their pres-
ence does not indicate injury to the sphincter.
Hemorrhoids consist of a stroma with blood ves-
sels, smooth muscles and supporting connective
tissue; and there is the anchoring connective tissue
system, which connects hemorrhoids to the inter-
nal sphincter and the conjoined longitudinal coat,
all consisting of muscle fibers (Haas et al. 1984).
Teramoto et al. reported that biopsies of sphinc-
ters were taken in patients with hemorrhoids but
no case of incontinence has been reported
(Teramoto et al. 1981). Khalil et al. (2000) found
skeletal muscle fibers and smooth muscles fibers
in histological specimens after sutured hemorrhoi-
dectomy and stapler hemorrhoidectomy. They
concluded that the histological presence of muscle
fibers in excised hemorrhoidal tissue neither
means sphincter injury nor incontinence (Khalil
et al. 2000).
In summary, in most instances, hemorrhoids
are treated conservatively; the surgeon is contact-
ed when conservative measures have failed or
complications, e.g., thrombosis, have occurred. 4°
prolapsed internal hemorrhoids are the main indi-
cation for hemorrhoidectomy: high (Parks) or
low (Milligan-Morgan) ligation with excision,
closed hemorrhoidectomy (Ferguson) or stapler
hemorrhoidectomy. Thrombosed external hemor-
rhoids are primary treated by incision and secon-
dary by excision. Complications after operative
treatment of external thrombosed hemorrhoids
are rare. After standard hemorrhoidectomy for
internal hemorrhoids approximately 10% may
have a complicated follow-up (bleeding, fissure,
fistula, abscess, stenosis, urinary retention, soil-
ing, incontinence); there may be concomitant dis-
ease, e.g., perianal cryptoglandular infection, caus-
ing complex fistula/abscess, which is associated
with an increased risk (30-80%) for complica-
tions, e.g., incontinence. Other treatment op-
tions, e.g., sphincterotomy, anal stretch, have
been accused to cause more complications, e.g., in-
continence in 30-50% of cases. However, inconti-
nence is a complex phenomenon; it is evident that
an isolated single injury is normally not a suffi-
cient cause, e.g., injury of the internal sphincter.
The majority of patients may present with prior
obstetric injury, perianal infection or Crohn’s dis-
ease and other comorbidity. Therefore all system-
ic and regional disorders, causing incontinence,
should be excluded before starting manometric,
neurophysiological and sonographic investiga-
tions. Variations and overlap in test results, pa-
tient-, instrument- or operator-dependent factors
ask for cautious interpretation. There is vast evi-
dence that the demonstration of muscle fibers in
hemorrhoidectomy specimens is a normal feature.
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Received: December 8, 2003 / Accepted: January 9, 2004
Address for correspondence:
René Gordon Holzheimer MD PhD
Praxisklinik Sauerlach (Center for Daycase Surgery)
Tegernseer Landstr. 8
D-82054 Sauerlach
Tel. +49-8104-887822
Fax +49-8104-887824
... There were six in group B and four in group A. While it decided to continue in 3 patients in group B, none of the patients in group A in the next day have still bloody ooze. Bloody ooze is now significantly more prevalent in group B as compared to group A. no one required a blood transfusion (Holzheimer RG, 2004). ...
... such dreaded complications led them to suggest a surgical procedure to cut away the sphincter. Due to the lack of accessibility of the device in our hospital, anal manometry was not included in this investigation (Galizia G et al, 2000;Holzheimer RG, 2004;Di BF et al, 1990). ...
Full-text available
Hemorrhoid, is one of the most common anal pathologies. It is considered as a big issue in our society, surgical treatment is one of the valid ways to treat hemorrhoids. Pain after surgery is the most important complication beside other complications. Piles are removed with overlying skin removed with hemorrhoidectomy. Pain intensity varies, depending on the patient's pain threshold. This research attempts to see if open hemorrhoidectomy by itself or hemorrhoidectomy and internal sphinctorotomy were effective in treating post-operative pain.
... These include rubber band ligation and injection sclerotherapy. Indications for an inpatient surgery are symptomatic hemorrhoids grade III-IV (12)(13)(14). Even though the effects of dietary factors and physical activity on the pathogenesis and disease course of hemorrhoidal disease are not yet completely understood, lifestyle modi cations are an integral part of the treatment, may prevent complications and improve the surgical outcome or even reduce the recurrence rate in hemorrhoidal disease (15). ...
... Moderate FI (11)(12)(13)(14)(15) Severe FI (16)(17)(18)(19)(20) 322 (85) 41 (11) 12 (3) 5 (1) CCFIS, Cleveland Clinic Fecal Incontinence Score/Wexner; FI, fecal incontinence; Values are absolute (relative) numbers or median (interquartile range). 1 Numbers are related to patients with a prior hemorrhoids surgery (n = 293); 2 n = 380. ...
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Background Although lifestyle modifications are an integral part of treatment and prevention of hemorrhoidal disease, it is largely unknown how lifestyle factors like diet and physical activity are characterized in patients with a history of advanced and invasively treated hemorrhoidal disease.Methods In a Northern German cross-sectional study, clinical characteristics and dietary and physical activity data of 386 patients were assessed via questionnaires at median 10 years after their first invasive hemorrhoidal treatment. Food and nutrient intake and physical activity levels of the hemorrhoid patients were compared with general population controls. Additionally, within the hemorrhoid patient cohort, dietary intake and physical activity were related to clinical characteristics using logistic regression analyses.resultsWhereas in men, there were no statistically significant differences in food intake between hemorrhoids patients and controls, women with a history of hemorrhoids had a significantly higher consumption of potatoes, nuts and animal fat, and a lower consumption of fruits, compared to women from the control group. Hemorrhoid patients reported slightly more gardening activities and less TV watching than controls. Within the hemorrhoid patient cohort, hemorrhoid grade, type of first therapy, need for further treatment, patients’ compliance for another surgery if necessary and current anal afflictions revealed individual associations with fiber, alcohol, animal fat and potato consumption and the amounts of home repair activities and sleeping time.Conclusions Although we could identify some statistically significant differences in dietary and physical activity behavior between hemorrhoid patients and controls and observed associations between clinical characteristics and lifestyle factors, some findings are, in parts, still inconsistent. Whether patients are following lifestyle recommendations as part of conservative hemorrhoid treatment and tertiary prevention and which patients are more adherent than others (e.g., high-grade vs. low-grade) needs further investigation.
... Hemorrhoidal disease is one of the most common and annoying disorders worldwide. The prevalence of symptomatic hemorrhoidal disease had been reported around 4% of the population [1][2][3]. The majority of hemorrhoids can be managed with conservative treatment; however, hemorrhoidectomy is still the definitive treatment for those Grade III or Grade IV hemorrhoids [4][5][6][7]. ...
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Background This study aims to assess the association between age and outcomes in patients undergoing hemorrhoidectomy. Methods This is a population-based cohort study. A retrospectively collected database with consecutive patients whose symptomatic prolapsed hemorrhoids managed by the LigaSure hemorrhoidectomy between Jan. 2015 and May 2017 was reviewed. Among 1238 patients, 1075 were under 65 years old (group 1), and 163 were 65 years old or older (group 2). Both groups were compared regarding baseline characteristics and surgical outcomes. Results All patients tolerated the whole course of the operation in the prone jackknife position without anesthetic-associated complications. There was no significant difference between these two groups regarding sex, hemorrhoids grade, operation time, duration of hospital stays, postoperative pain score, analgesic consumption, total postoperative complications, re-admission rate, reoperation rate and follow-up times. The multivariate logistic regression analysis that may contribute to postoperative complications revealed no significant difference for all complications between both groups. Conclusion The LigaSure hemorrhoidectomy for elderly patients is safe and effective without significant difference in short-term operative outcomes and all complication rates, compared with younger patients.
... (11) However, the complication rate after standard haemorrhoidectomy is approximately 10% (pain, bleeding, infection, fissure, abscess, fistula, anal stenosis, soiling) with postoperative pain reported in scores up to 8 on the visual analogue scale and anal incontinence in up to 33% of cases. (12)(13)(14) The deleterious effects of a well-performed haemorrhoidectomy on anal continence have been known for many years. In a study by Bennett et al. (15), 26% of haemorrhoidectomy patients had one or more defects in anal control 3 years postoperatively. ...
Introduction: Haemorrhoids are a very common disease, with a great economic burden. Many treatments have been developed for trying to solve the problem, being the standard not yet found. In 1995, Doppler-guided haemorrhoidal artery ligation was introduced, aiming to reduce postoperative pain and complications. In this work, an evolu-tion of the aforementioned surgical technique was described. Materials and methods: 183 patients treated with standard Doppler-Guided Haemorrhoidal Artery Ligation were statistically compared with 225 patients dealt with Colour Doppler-Guided Haemorrhoidal Artery Ligation. The procedures were performed under local anaes-thesia with patients in lithotomy position. A special proctoscope and a dedicated Colourdoppler US probe were employed in the second group. Superior haemorrhoidal artery terminal branches were con-secutively ligated according to provided technique in the first group and under vision in the second. In all cases, each ligation was followed by mucopexy. Results: No significant differences between the two groups, in terms of post-operative pain, early complications (bleeding, urinary retention, incontinence) or patient satisfaction, were demonstrated. Recurrence rate was significantly higher in patients treated with stan-dard DG-HAL. No late complications (after one-year follow-up) were registered in both groups. Conclusions: Colour Doppler-Guided Haemorrhoidal Artery Li-gation represents an ideal management for 1-day surgery, and fulfils the requirements of minimally invasive surgery in patients with III-IV grade haemorrhoids. The absence of complications and the evidence of significant wellness of patients are the best advantages. Colour Doppler-Guided Haemorrhoidal Artery Ligation is a safe and easy procedure with good results and a very short-time training. It could be considered an easy and reliable method to treat symptomatic haemorrhoids.
... Hemorrhoidectomy is considered to be an effective method for the treatment of III-IV degree symptomatic hemorrhoids. [4] Open hemorrhoidectomy is still the most common surgery for hemorrhoids, despite the emergence of many surgical methods. [5] Pain is a common complication after hemorrhoidectomy, with moderate and severe pain accounting for 65% of the total number of patients, [6] affecting patients' recovery and prolonging hospital stay. ...
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Background: Pain is a common complication after mixed hemorrhoids, which seriously affects the recovery of patients and prolongs the length of hospital stay. Acupoint catgut embedding has advantages in improving a variety of acute and chronic pain diseases, but there is still a lack of rigorous randomized controlled studies to verify its efficacy and safety in the treatment of postoperative pain of mixed hemorrhoids. Therefore, the purpose of this randomized controlled trial is to evaluate the clinical efficacy of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids. Methods: This is a prospective randomized controlled trial to study the efficacy and safety of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids. Approved by the clinical research ethics committee of our hospital, the patients were randomly divided into observation group and control group according to 1:1. The observation group received acupoint catgut embedding before the operation, while the control group received no special treatment. The efficacy and safety indexes were concerned after the operation, and the observation indexes included: resting state and visual analogue scale (VAS) score during defecation, postoperative hospitalization time, total amount of analgesic use, adverse reactions, etc. Finally, we carried on the data statistical analysis through the SPSS version 19.0. Discussion: This study will evaluate the efficacy and safety of acupoint catgut embedding in the treatment of postoperative pain of mixed hemorrhoids, and the results of this study will provide a new idea for the selection of postoperative analgesia for mixed hemorrhoids resection. Trial registration: OSF Registration number: DOI 10.17605/OSF.IO/T2ZGY.
... This procedure, when conducted below the dentate line, may affect many sensitive nerve endings and create tight and thin layers of anoderm, leading to any number of complications. [5,6] Moreover, men who underwent hemorrhoidectomy have eliminated distressing symptoms that affected on erectile functions (EFs) that do not necessarily causing EDs. It is important to understand the changes that can occur as a result of this surgical procedure on EF. ...
... Treatment of hemorrhoids depends mainly on the stage of the disorder and symptoms [4]. Hemorrhoidectomy is considered an effective method for third and fourth degree symptomatic hemorrhoids [5]. Many surgical techniques have been proposed; however, open hemorrhoidectomy is still the most common performed operation for hemorrhoids. ...
... This procedure, when conducted below the dentate line, may affect many sensitive nerve endings and create tight and thin layers of anoderm, leading to any number of complications. [5,6] Moreover, men who underwent hemorrhoidectomy have eliminated distressing symptoms that affected on erectile functions (EFs) that do not necessarily causing EDs. It is important to understand the changes that can occur as a result of this surgical procedure on EF. ...
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Introduction: Erectile dysfunction (ED) is a highly prevalent condition among men all over the world and commonly associated with undiagnosed medical diseases as chronic pelvic pain and hemorrhoid. Objective: The purpose of this study was to study the impact of surgical hemorrhoidectomy on sexual function in men with erectile dysfunction (ED). Materials and Methods: In a prospective manner, we studied the effect of surgical hemorrhoidectomy on erectile function (EF) in male patients with ED. Hemorrhoidectomy was carried out in 82 patients with clinical hemorrhoid associated with ED (Group 1) and compared with 81 patients without operative intervention (Group 2; control). The primary efficacy variable was the mean change in the International Index of Erectile Function (IIEF) questionnaire. Results: In Group 1, the IIEF questionnaire increased significantly after hemorrhoidectomy, from 15.56 to 27.37 (P < 0.001), indicating improvement of EF. Thirty-six patients (41.1%) showed improvement of EF compared to 5.3% in the control group (P < 0.001). In Group I, but not in Group II, IIEF values increased significantly when compared with preoperative values (P < 0.001). Conclusion: We concluded that surgical hemorrhoidectomy is clearly related to improvement of EF in male hemorrhoid patients with ED.
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Excerpt "Surgical Treatment-Evidence-Based and Problem-Oriented" is based upon a concept which the editors believe will become increasingly important in the preparation of clinical textbooks in the 21st century, namely the quality of the evidence upon which currently accepted clinical practice is based needs to be assessed frankly and taken into account when recommendations for patient treatment are made. As is apparent in many of the chapters in this volume, the authors are frequently forced to conclude that a higher level of evidence than is currently available would be necessary in order establish the validity of the currently accepted management of a wide variety of common surgical problems. The editors believe this is a fact of which both students and surgical practitioners need to be aware, so that they may be prepared to update and alter their clinical decision making on the basis of higher levels of evidence when these become available. The editors also hope that increasing awareness of the low level of evidence upon which much present day surgical practice is based will prompt surgeons from many countries to plan or at least participate in clinical trials to achieve a higher quality of evidence upon which to base a more rational clinical practice.
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Hemorrhoids are a frequently occurring disorder widely believed to be caused by chronic constipation. In the present study, the epidemiology of hemorrhoids was evaluated and compared with the epidemiology of constipation. The analysis was based on 4 data sources: from the United States, the National Health Interview Survey, the National Hospital Discharge Survey, and the National Disease and Therapeutic Index; from England and Wales, the Morbidity Statistics from General Practice. Results showed that 10 million people in the United States complained of hemorrhoids, corresponding to a prevalence rate of 4.4%. In both sexes, a peak in prevalence was noted from age 45–65 yr, with a subsequent decrease after age 65 yr. The development of hemorrhoids before age 20 yr was unusual. Whites were affected more frequently than blacks, and increased prevalence rates were associated with higher socioeconomic status. This was in contrast to the epidemiology of constipation, which demonstrated an exponential increase in prevalence after age 65 yr and was more common in blacks and in families with low incomes or low social status. The data presented illustrate differences in the epidemiologic behavior of hemorrhoids and constipation, calling the presumption of causality between constipation and hemorrhoids into question.