Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Incidence is difficult to ascertain as many people with the condition will never consult with a medical practitioner, although one study found 10 million people in the USA complaining of the disease.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical question: What are the effects of treatments for haemorrhoidal disease? We searched: Medline, Embase, The Cochrane Library, and other important databases up to May 2008 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
We found 44 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
In this systematic review we present information relating to the effectiveness and safety of the following interventions: closed haemorrhoidectomy, haemorrhoidal artery ligation, infrared coagulation/photocoagulation, injection sclerotherapy, open excisional (Milligan-Morgan/diathermy) haemorrhoidectomy, radiofrequency ablation, rubber band ligation, and stapled haemorrhoidectomy.
Haemorrhoids are cushions of submucosal vascular tissue located in the anal canal starting just distal to the dentate line. Haemorrhoidal disease occurs when there are symptoms such as bleeding, prolapse, pain, thrombosis, mucus discharge, and pruritus.
Incidence is difficult to ascertain as many people with the condition will never consult with a medical practitioner, although one study found 10 million people in the USA complaining of the disease.
First- and second-degree haemorrhoids are classically treated with some form of non-surgical ablative/fixative intervention, third-degree treated with rubber band ligation or haemorrhoidectomy, and fourth-degree with haemorrhoidectomy.
Rubber band ligation is known to be highly effective in treating first-, second-, and some third-degree haemorrhoids.
Rubber band ligation can produce some immediate adverse effects, and the clinician should therefore always gain informed consent.
Closed haemorrhoidectomy seems an effective treatment for relieving symptoms in people with first- to fourth-degree haemorrhoids.
Although effective, closed haemorrhoidectomy does appear to be associated with greater postoperative complications than haemorrhoidal artery ligation.
Open excisional haemorrhoidectomy may also be effective in treating all grades of haemorrhoids, although it produces similar levels of adverse effects to closed haemorrhoidectomy.
Infrared coagulation may be as effective as rubber band ligation and injection sclerotherapy in the treatment of first- and second-degree haemorrhoids.
We found insufficient evidence to judge the effectiveness of injection sclerotherapy,
radiofrequency ablation, or haemorrhoidal artery ligation.
While stapled haemorrhoidectomy seems effective in treating people with more severe haemorrhoids, some of the adverse effects are potentially life threatening, and so the procedure should only ever be carried out by a fully trained colorectal surgeon.