CLINICAL PRACTICE GUIDELINES The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids Bradley R. Davis, M.D. • Steven A. Lee-Kong, M.D. • John Migaly, M.D. Daniel L. Feingold, M.D. • Scott R. Steele, M.D. Prepared by the Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons he American Society of Colon and Rectal Surgeons ing the propriety of any specific procedure must be made (ASCRS) is dedicated to assuring high-quality pa- by the physician in light of all of the circumstances pre- Ttient care by advancing the science, prevention, sented by the individual patient. and management of disorders and diseases of the colon, rectum, and anus. The Clinical Practice Guidelines Com- mittee is composed of Society members who are chosen STATEMENT OF THE PROBLEM because they have demonstrated expertise in the specialty Symptoms related to hemorrhoids are very common in of colon and rectal surgery. This committee was created to the Western hemisphere and other industrialized societies. lead international efforts in defining quality care for condi- Although published estimates of prevalence are varied,1,2 tions related to the colon, rectum, and anus. This is accom- it represents one of the most common medical and surgi- panied by developing Clinical Practice Guidelines based on cal disease processes encountered in the United States, re- the best available evidence. These guidelines are inclusive sulting in >2.2-million outpatient evaluations per year.3 A and not prescriptive. Their purpose is to provide informa- large number of diverse symptoms may be, correctly or in- tion on which decisions can be made rather than to dictate correctly, attributed to hemorrhoids by both patients and a specific form of treatment. These guidelines are intended referring physicians. As a result, it is important to identify for the use of all practitioners, healthcare workers, and pa- symptomatic hemorrhoids as the underlying source of the tients who desire information about the management of anorectal symptom and to have a clear understanding of the conditions addressed by the topics covered in these the evaluation and management of this disease process. guidelines. It should be recognized that these guidelines These guidelines address both diagnostic and therapeutic should not be deemed inclusive of all proper methods of modalities in the management of hemorrhoidal disease. care or exclusive of methods of care reasonably directed to obtaining the same results. The ultimate judgment regard- METHODOLOGY These guidelines are built on the ASCRS Practice Param- Supplemental digital content is available for this article. Direct URL ci- tations appear in the printed text, and links to the digital files are pro- eters for the Management of Hemorrhoids published in vided in the HTML and PDF versions of this article on the journal’s Web 2011.4 A literature search of MEDLINE, PubMed, and the site (www.dcrjournal.com). Cochrane Database of Collected Reviews was performed, expanding on the previous literature search from 1996 Earn Continuing Medical Education (CME) credit online at cme.lww.com. and updated through April 2017 (see Supplemental Search Funding/Support: None reported. Strategy, http://links.lww.com/DCR/A532). Key word combinations included hemorrhoid, internal and external Financial Disclosure: None reported. hemorrhoids, hemorrhoid disease, thrombosed hemorrhoid, rubber band ligation, hemorrhoidopexy, procedure for pro- Correspondence: Scott R. Steele, M.D., 9500 Euclid Ave, A30, Cleveland, lapse and hemorrhoids (PPH), and stapled hemorrhoido- OH 44915. E-mail: Steeles3@ccforg pexy, Doppler-guided hemorrhoidopexy, hemorrhoidectomy, Dis Colon Rectum 2018; 61: 284–292 Milligan–Morgan, and Ferguson. Directed searches of the DOI: 10.1097/DCR.0000000000001030 embedded references from the primary articles were also © The ASCRS 2018 performed in selected circumstances. The final source ma- 284 DISEASES OF THE COLON & RECTUM VOLUME 61: 3 (2018) Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. DISEASES OF THE COLON & RECTUM VOLUME 61: 3 (2018) 285 terial used was evaluated for the methodologic quality, the The diagnosis of hemorrhoids is almost always a clinical evidence base was examined, and a treatment guideline one and should start with a medical history, with great was formulated by the subcommittee for this guideline. care taken to identify symptoms suggestive of hemor- When agreement was incomplete regarding the evidence rhoidal disease and risk factors such as constipation,6 fol- base or treatment guideline, consensus from the commit- lowed by a focused physical examination. The cardinal tee chair, vice chair, and 2 assigned reviewers determined signs of internal hemorrhoids are painless bleeding with the outcome. The final grade of recommendation and lev- bowel movements with intermittent protrusion. Focus el of evidence for each statement were determined using should be on the extent, severity, and duration of symp- the Grades of Recommendation, Assessment, Develop- toms such as bleeding and prolapse, issues of perineal hy- ment, and Evaluation system (Table 1).1,5 Members of the giene, and presence or absence of pain. A careful review of ASCRS Clinical Practice Guidelines Committee worked fiber intake and bowel habits, including frequency, consis- in joint production of these guidelines from inception to tency, and ease of evacuation, should also be performed, final publication. Recommendations formulated by the because constipation predisposes patients to hemorrhoid- subcommittee were then reviewed by the entire Clinical al disease.6,7 A careful assessment of fecal incontinence Practice Guidelines Committee for edits and recommen- symptoms should also be made, because this may affect dations. Final recommendations were approved by the management decisions, to include the possibility of surgi- ASCRS Clinical Guidelines Committee and ASCRS Execu- cal treatment. Physical examination in the prone, knee– tive Committee. In general, each ASCRS Clinical Practice chest, or lateral decubitus position should include visual Guideline is updated every 3 to 5 years. inspection of the anus, as well as digital rectal examina- tion to evaluate for other anal pathology and sphincter EVALUATION OF HEMORRHOIDS integrity. In addition, an evaluation of the patient while straining on the bathroom will assist in the diagnosis of 1. A disease-specific history and physical examination should hemorrhoidal prolapse, as well as exclude full-thickness be performed, emphasizing degree and duration of symp- rectal prolapse. An anoscopic examination should be per- toms and risk factors. Grade of Recommendation: Strong formed to assess the anatomy.8 Internal hemorrhoids, lo- recommendation based on low-quality evidence, 1C. cated above the dentate line, can be assigned a grade based TABLE 1. The Grades of Recommendation, Assessment, Development, and Evaluation System Grading Recommendations Description Benefit vs risk and burdens Methodologic quality of supporting evidence Implications 1A Strong Benefits clearly outweigh RCTs without important limitations Strong recommendation, can recommendation, risk and burdens or vice or overwhelming evidence from apply to most patients in high-quality versa observational studies most circumstances without evidence reservation 1B Strong Benefits clearly outweigh RCTs with important limitations Strong recommendation, can recommendation, risk and burdens or vice (inconsistent results, methodologic apply to most patients in moderate-quality versa flaws, indirect or imprecise) or most circumstances without evidence exceptionally strong evidence from reservation observational studies 1C Strong Benefits clearly outweigh Observational studies or case series Strong recommendation but recommendation, risk and burdens or vice may change when higher- low- or very-low- versa quality evidence becomes quality evidence available 2A Weak Benefits closely balanced RCTs without important limitations Weak recommendation, best recommendation, with risks and burdens or overwhelming evidence from action may differ depending high-quality observational studies on circumstances or patient evidence or societal values 2B Weak Benefits closely balanced RCTs with impo0rtant limitations Weak recommendation, best recommendations, with risks and burdens (inconsistent results, methodologic action may differ depending moderate-quality flaws, indirect or imprecise) or on circumstances or patients’ evidence exceptionally strong evidence from or societal values observational studies 2C Weak Uncertainty in the estimates Observational studies or case series Very weak recommendations; recommendation, of benefits, risks, and other alternatives may be low- or very-low- burden; benefits, risks, equally reasonable quality evidence and burden may be closely balanced Adapted with permission from Chest 2006;129:174–181.5 RCT = randomized controlled trial. Copyright © The American Society of Colon & Rectal Surgeons, Inc. Unauthorized reproduction of this article is prohibited. 286 DAVIS ET AL: MANAGEMENT OF HEMORRHOIDS on the definitions in Table 2, which may help to guide TABLE 3. Indications for Complete Colon Evaluation therapy. Laboratory evaluation is not typically required for diagnostic purposes. 1. Age ≥50 y if no complete examination within 10 y 2. Age ≥40 y or 10 y younger than the age at diagnosis with history