First Stop: Hemorrhoids


These are very common 50-80% of us all will at sometime be bothered by them. Most are bothered by bleeding, swelling and prolapse outside of the anus, pain from mild to severe, itching and burning discomfort.

There are no natural therapies to make hemorrhoids reliably disappear, that we are aware of. They can only make them feel better or bleed less while you are taking them. They can bother you lots less if you become less constipated or after giving birth. Some do disappear when you do this and no matter what you should ensure that your lifestyle is modified to prevent constipation in the long term. That is to be addressed in our next installment.


External hemorrhoids are the result of intermittent internal hemorrhoidal swelling, and generally do not occur in isolation. When they do we can remove them separately. These leave open wounds generally after surgery and recur frequently immediately or distantly after surgery. They can be painful and bleed after surgery.

These are made worse with things like constipation, straining, and pregnancy. This is very difficult to treat effectively. We try to treat the entire anus as necessary, sometimes requiring surgery. This is the most effective, both in the short and long term.


Internal or Mixed:

Grade I (primary) – These slide below the dentate line with strain but retract with relaxation; patients are typically treated with dietary changes, including increased fiber intake; if hemorrhoids persist, rubber band ligation may be offered. These can be associated with leaving pain and discomfort which in a minority of situations, require surgical therapy.

Grade II – These prolapse past the anal verge but reduce spontaneously; patients are typically treated with rubber band ligation and rarely require surgery.

Grade III – These prolapse past the anal verge and must be reduced with a finger (washed thoroughly afterwards to prevent COVID-19 infection). Depending on the size of the hemorrhoids and the symptoms noted, patients may be treated with rubber band ligation, or surgery

Grade IV – These prolapse past the anal rim and are both internal as well as external, with inability to push it back in. Surgical treatment, removal (hemorrhoidectomy) is indicated, banding is almost always not successful, and not tried.


Two main effective options are available:

Traditional ‘cutting out’ hemorrhoidectomy:

Is this technique and the surgeon will strip the entire vascular complex of blood vessels off the muscle with a scalpel or other similar cutting device we then suture legate the upper blood supply, higher up where the rectum meets anus. The surgeon then leaves this to heal by itself or sutures the cut edges together.

Non-cutting out surgical options:

THD uses ultrasound to locate the terminating branches of the hemorrhoidal arteries. Once the artery is located the surgeon uses an absorbable suture to ligate or “tie-off” the arterial blood flow. The venous “out flow” remains to “shrink” the cushion. This is done usually without removal of tissue. If necessary the surgeon will perform a hemorrhoidopexy to repair the prolapse. Again, this is done with suture and no excision of tissue. This repair restores and “lifts” the tissue back to its anatomical position.

Generally all surgery on the anus tends to leave one with varying degrees of pain, burning discomfort, inability to pass stool due to stenosis or tightness, very rare incontinence, fistula(a tunnel between the inside and the outside) or abscess. The more invasive the operation the more frequent the side effects.

The initial assessment for hemorrhoids involves a look inside with a flexible camera and perhaps an attempt at treatment with the application of a rubber band and cold therapy.

Most patients with hemorrhoids can be treated without surgery, to varying degrees of success and conversely recurrence rates. Almost all advanced disease requires either multiple procedures to keep hemorrhoidal symptoms at bay. Surgery is generally required to rid the sufferer with a reasonable chance of permanence of cure.


About the author:

Dr. Ash Maharaj, BSc MB BCh FACS

Fellow of the American College of Surgeons
Member of American College of Colorectal Surgeons
Outpatient Gastrointestinal Medicine and Natural Tissue Hernia Repairs
Clinical Lead Minimally Invasive Hemorrhoid Therapies ProctoCAN

Dr. Maharaj obtained an undergraduate degree in Biology/Physiology from the University of Western Ontario, and subsequently completed a medical degree at the Royal College of Surgeons in Ireland. A residency followed in General Surgery associated with Yale University in Connecticut, USA, which included a surgical research fellowship in the Department of Pediatric Surgery.

After completing 7 years of training in General Surgery, he worked as an acute care/minimal invasive surgeon at Ross Memorial Hospital in Lindsay, Ontario Canada.

Clinical interests since then have been in upper and lower G.I. endoscopy as well as outpatient hernia surgery and anorectal surgery here in Toronto these last, 20 years.