Haemorrhoidal disease (HD) is the most common anorectal reason for medical appointments. A population study conducted in Europe and both Americas estimated the incidence of HD at 11% (1). Most of the respondents reported mild symptoms (71%). Women and patients with comorbidities were statistically more often affected. Interestingly, only 40% of the respondents reported to a doctor due to disease symptoms. The peak incidence is between 45 and 65 years of age. A drop in the incidence is observed after 65 years of age. Haemorrhoids are rare in patients under 20 years of age. Pregnant women are a particularly vulnerable group, with hemorrhoidal symptoms reported by 85% of women in the second and third trimester, including 7.9% of women developing haemorrhoidal thrombosis in the last trimester. The systematic drop in the number of conventional haemorrhoidectomies observed in the following decades of the 20th century does not indicate a lower morbidity, but only a shift in the treatment burden towards minimally invasive surgical techniques performed mostly on an outpatient basis (3). Anatomically, haemorrhoids are arteriovenous connections located on the border of the anal canal and rectum, in the so-called transitional zone, where sensory receptors that distinguish the contents of the rectal ampulla are found. The definition of haemorrhoidal disease encompasses a situation where the described arteriovenous plexuses become significantly enlarged, prolapsed, or when disease symptoms (most often bleeding) occur.

The grade of the disease is an important aspect in qualification for treatment. Banov grading system (2), commonly and interchangeably known as the Goligher’s classification (1985), is the most commonly used grading system. Attempts to develop new classification systems have been made in recent years. The BPRST classification, which considers such symptoms as Bleeding [B], Prolapse [P], Reduction [R], Skin tag [S], and Thrombosis [T], is one of the more interesting grading systems. Despite these proposals, the Banov classification, which distinguishes 4 grades of the disease and considers the degree of haemorrhoidal prolapse, has been the most common classification system so far.

Apart from the stage of the disease, patient’s age, general health condition and expectations, including the recovery time and return to work, should be considered when choosing the treatment method.

While the majority of researchers are in agreement as to the use of conservative treatment in the initial stage of the disease, the treatment of grade II and III patients raises much controversy, and the developed therapeutic standards differ from country to country.

We present therapeutic standards developed in the United States, Japan, and some European countries.

The American standards were developed by the American Society of Colon and Rectal Surgeons (4). Diagnosis of haemorrhoidal disease:

• painless bleeding with bowel movements is the cardinal sign

• diagnosis is based on a thorough medical history:

• bleeding severity,

– duration of symptoms – bleeding and prolapse,

– hygiene,

– incontinence symptoms – mainly as a factor influencing further treatment decisions - qualification for surgical treatment,

• the diagnosis of the causes of bleeding must be confirmed endoscopically (colonoscopy).

• general indications:

– diet modification,

– advice on bowel movement habits,

• symptomatic treatment:

– phlebotonics,

– topical ointments recommended for short-term use due to the risk of an allergic reaction with chronic use.

The goal of outpatient treatment is to reduce the size and vascularisation of haemorrhoids, improve the attachment of the haemorrhoid, and reduce prolapse:

• Grade I, II, sometimes, III haemorrhoidal disease:

– rubber band ligation (RBL)

– sclerotherapy with 5% phenol solution in almond or vegetable oil or polidocanol

– infrared coagulation.

• Grades III and IV:

• excisional haemorrhoidectomy – recommended for patients who have failed outpatient procedures or have not consented to them, with grade III and IV hemorrhoidal disease and hypertrophy of marginal anodermal folds:

– open (Milligan-Morgan),

– closed (Ferguson),

a. excision using a circular stapler – patients with mucosal prolapse:

– possible specific complications, e.g. rectovaginal fistula, bleeding from the staple line, stenosis at the anastomotic level,

b. Doppler-guided hemorrhoidal artery ligation (DG-HAL):

– in patients with any grade of haemorrhoidal disease (grade I-IV) with a relapse rate from 3 to 60% in cases of grade IV,

• adjunct (analgesic) therapy:

– pharmacological sphincterotomy - the use of ointments with calcium channel blockers reduces the use of narcotic analgesics,

– lateral sphincterotomy - reduced postoperative pain, but increased risk of incontinence,

– botulinum toxin,

• marginal thrombosis - excision in the early phase of the disease contributes to faster resolution of symptoms, lower risk of recurrence and longer remission time.

American experts largely focus on the diagnosis, including a recommendation to perform colonoscopy before treatment onset. In the section devoted to diagnosis, the high value of the standards is emphasised by the inclusion of the symptom of incontinence - mainly as a factor influencing further decisions on qualification for surgery. It is known that haemorrhoids seal the anal canal and are responsible for gas retention in approximately 30% of cases; therefore patients with symptoms of incontinence should be carefully qualified for haemorrhoid surgery, which may consequently aggravate the symptoms of gas incontinence and soiling.

It is debatable whether lateral sphincterotomy should be recommended as analgesic treatment, and whether DGHL method should be proposed for patients regardless of the stage of the disease. We believe that DGHL is not an effective method for grade IV patients unless the procedure is supplemented with RAR, i.e. lifting the prolapsing mucosa.

In the American standards, infrared photocoagulation has an established place in the outpatient treatment of haemorrhoids, while in Poland, the technique is currently used only occasionally and seems to be ineffective.

French standards were developed by the French Association of Coloproctology (Sociètè Nationale Française de Colo-Proctologie). Expert surgeons and gastroenterologists participated in developing these guidelines (5).

• rectal ointments in cases of symptom exacerbation, recommended short-term use,

• high-fiber diet in the event of disease exacerbation and as a relapse prevention,

• phlebotonics for symptom aggravation - bleeding and pain, short-term treatment.

Conservative treatment of HD overlapping with other symptoms or diseases:

• thrombosis - recommended management:

– non-steroidal anti-inflammatory drugs,

– topical agents with steroids,

– local and general analgesics,

– agents to improve intestinal passage,

– phlebotonics,

– coexisting anal fissure:

– agents to improve intestinal passage – anti-constipation,

– rectal ointments,

• coexisting inflammatory bowel diseases:

– treatment of the underlying disease,

• pregnant and postpartum women:

– agents to improve intestinal passage – anti-constipation,

– rectal ointments,

– analgesics - paracetamol.

• rubber bands, infrared coagulation, and sclerotherapy for grade I and II HD after failure of conservative treatment.

a. rubber bands:

• may be proposed before the decision to perform a surgery for patients with mild prolapse,

• banding 3 haemorrhoids during one procedure is as effective as in 3 separate procedures,

• the procedure is not recommended for grade III haemorrhoids with circular prolapse and grade IV,

• in patients without mucosal prolapse, banding should be performed after failure of infrared coagulation,

• improved intestinal passage increases therapeutic efficacy

b. there are no indications for antibiotic prophylaxis in rubber band ligation or sclerotherapy,

c. contraindications to surgical treatment:

• IBDs in the exacerbation phase,

• perineal abscess,

• pregnancy,

• diseases associated with significant immunosuppression.

• recommended for:

– haemorrhoidal disease - documented in a clinical examination with the exclusion of other bleeding aetiology,

– poorly controlled chronic and recurrent haemorrhoidal disease (grade I-III) (regulation of bowel movements and phlebotropics),

– chronic haemorrhoidal disease for which instrumental treatment is ineffective or not recommended,

• haemorrhoidectomy with pedicle ligation – at any stage of advancement (simultaneous excision of the anal fissure is not recommended),

• stapler hemorrhoidectomy - grade II and III (not recommended for grade IV),