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Editorials Scalpel surgery is now rarely needed

Modern treatments for internal haemorrhoids

BMJ 1997; 314 doi: (Published 26 April 1997) Cite this as: BMJ 1997;314:1211
  1. John L Pfenninger, Director (
  1. a The National Procedures Institute, Midland, Michigan 48640, USA

    Almost everyone suffers from haemorrhoids at some time in their lives. The symptoms include bleeding, prolapsing tissue, fullness after defecation, and pain. Bleeding can mimic or mask the diagnosis of cancer and must be thoroughly evaluated. In most cases, however, swift, simple, and effective treatment can be given in an outpatient clinic or a health centre.1 2 3 4 The key to understanding the feasibility of outpatient treatment is that there are no sensory nerve fibres above the dentate (pectinate) line in the anus, which is at the squamomucosal junction. Internal haemorrhoids arise above this line, so they can be treated without an anaesthetic. External haemorrhoids develop below the dentate line and are exquisitely sensitive. Little preparation is needed for the treatment of internal haemorrhoids, but an enema will make them easier to see as well as making the procedure more aesthetically acceptable.

    Haemorrhoids are graded by the degree of prolapse, and this grading determines the most appropriate methods of treatment. First degree haemorrhoids are merely visible vessels, second degree lesions prolapse with defecation but return spontaneously, third degree lesions prolapse and require manual replacement, and fourth degree lesions remain prolapsed out of the anal canal despite attempts …

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