Hemorrhoids are very common and are associated with conditions such as constipation, heavy lifting, and labor. The usual complaint is pain with or without bleeding; however, it is possible to have painless hemorrhoidal bleeding. Grade I hemorrhoids are not apparent on exam and grade II hemorrhoids are seen only with straining. Grade III hemorrhoids are immediately visualized and grade IV hemorrhoids are gangrenous.
The asymptomatic patient requires no surgery. Grade I,II hemorrhoids usually resolve with fluids, fiber, and exercise; it would not be inaccurate to say that many are over treated using rubber bands. Surgery is offered to acceptable risk patients with grade III hemorrhoids who do not improve with conservative management. Grade IV hemorrhoids require surgery.
Hemorrhoidectomies are performed under general anesthesia as an outpatient. “ Preemptive blockade” is defined as the administration of a local anesthetic before the procedure, no different than a preemptive strike against an enemy. Preemption with a long acting local anesthetic (Marcaine) coupled with a topical anesthetic (dibucaine gel) dramatically reduce postoperative pain. In fact, some patients do not need narcotics or even Tylenol. Warm baths are begun on the first postoperative day, and most patients return to work within a week.