Sievering Clinic

Competence Centre for Minimally Invasive Medical Services


haemorrhoid_1Internal haemorrhoids are varicose veins of the anus. Nearly every patient visiting our clinic with anal problems comes in complaining of “painful haemorrhoids”. They are often assigned blame for anal fissures and itching, perianal dermatitis, condylomata acuminata, fistula-in-ano and incontinence.

Not surprisingly, only a minor percentage of these complaints are actually due to haemorrhoids. It is essential, therefore, that treatment options are only undertaken if they are truly symptomatic. The mere presence of haemorrhoids is not an indication for any therapeutic intervention.

Anatomy and Classification

images_prokto_haem-anatomieInternal haemorrhoids are found in the right anterior, right posterior and left lateral positions within the anal canal. This was originally thought to be due to the terminal branching of the superior mesenteric artery, however recent studies have refuted this.
The position of haemorrhoids within the anal canal however remains remarkably consistent.Haemorrhoids can be divided into those originating above the dentate line, which are termed internal; those originating below the line are termed external.

External haemorrhoids or piles are rarely symptomatic unless a thrombus builds up in the plexus.
Haemorrhoids are thought to represent engorgement or enlargement of the normal fibro-vascular plexus cushions lining the anal canal.
It has been postulated that chronic straining secondary to constipation, gas passing or diarrhoea results in a pathologic response in haemorrhoids.

Internal haemorrhoids are classified by history and not by physical examination.

Grading of haemorrhoids

Grade 1 bleeding without prolapse
Grade 2 prolapse with spontaneous reduction
Grade 3 prolapse with manual reduction
Grade 4 incarcerated, irreducible prolapse

This system has been in place for many years and correlates relatively well with treatment algorithms (ie Grade 1 and 2 haemorrhoids are often successfully treated by non operative means while Grade 3 and Grade 4 haemorrhoids are more likely to require surgery).