Many patients who think they have hemorrhoids simply don't. They see some bleeding or a lump and have a little pain and itching, and they automatically assume they can attribute those symptoms to hemorrhoids. Often the problem is something more complicated or, conversely, something as simple as an itchy bottom. When the condition does turn out to be a hemorrhoid, it can be either internal or external. There are four types of external hemorrhoids:

• Grade one. Here, the veins have increased in size and number, but they may not hurt or itch. The patient will come in because of some bleeding, if they notice it at all.
• Grade two. The internal hemorrhoid has prolapsed, but it spontaneously reduces itself. That is, it comes down out of the rectum, but goes back up on its own. The discomfort increases as the condition becomes more serious.
• Grade three. The pain, burning, itching and bleeding symptoms increase because the prolapse no longer self-reduces; it has to be manually pushed back into the rectum.
• Grade four. The hemorrhoid has to be pushed up, but it's non-reducible. This is the most painful kind, marked by burning and bleeding.

How to handle
There aren't exactly any new developments in the treatment area. Cryosurgery — the rapid freezing and thawing of the affected tissue — has fallen out of favor and infrared therapy seems to have taken its place, experiencing an upswing in popularity in recent years. Manufacturers are trying various methods, but no minimally invasive treatment has really replaced hemorrhoidectomy. Here's a look at treatment modalities:

• Sclerotherapy. This office-based procedure consists of an injection of phenol almond oil into the hemorrhoid vein. This causes it to harden, which cuts off the blood supply and causes the hemorrhoid tissue to die. The scar that forms in its place then holds surrounding tissue and veins in place so they no longer bulge into the rectum. Appropriate for grade one conditions.
• Rubber bands. A treatment for both grades one and two, the surgeon ties off the hemorrhoid at its base to cut off the blood flow, which again kills the tissue and forms the reinforcing scar. This procedure can be performed in the office setting.
• Infrared photocoagulation. Using a laser or photocoagulator, the surgeon focuses an intense beam of light on the hemorrhoid. This therapy works backward as compared to the previous two. The light creates a scar, which cuts off the blood supply, instead of a cut-off blood supply and dead tissue causing the scar. My reservations about this procedure, which works for grade one and grade two conditions, is that you don't have much control over the edges, which may cause some wound breakdown. Further, there's a safety issue any time you're using a laser for a procedure — and the apparatus is very expensive, which decreases the cost-effectiveness of the procedure.
• PPH stapled hemorrhoidopexy. You can handle grade two and grade three hemorrhoids with this minimally invasive technique. I'll give you the basic version of how the device involved in the procedure works. The surgeon creates a purse string on a circular stapling apparatus; he puts the purse string around the hemorrhoid at its base; then he fires the stapler. The result is that the affected tissue is lifted and repositioned, its blood flow cut off by the tightening of the string. While the leftover tissue is excised, it's called a pexy because you're not removing all of the hemorrhoid down to its root, just the inflamed tissue. The technique is efficient, but it has its issues, just like any other. First, the equipment is on the expensive side, though you may be able to make up for it in efficiency. Post-op, the patient will have a staple line inside, and if he practices anal intercourse or suffers an anal fissure, there will be complications. You really have to practice thorough post-op teaching with this procedure.
• Hemorrhoidectomy. The procedure is what the name implies: the cutting out of the affected tissue. It's performed in a hospital or ASC. Depending on the patient's condition — whether he has associated hypertrophies of the muscle, for example — you'll perform an excision of the external hemorrhoid or both the external and part of the internal tissue, and you may even have to perform a partial sphincterectomy. Hemorrhoidectomy is the gold standard for treating grade three and grade four hemorrhoids because you get rid of the tissue, eliminating the problem altogether. Almost all fourth-degree hemorrhoids will be treated surgically.

Depending on whether a patient has a thrombosis, he may go right to surgery from the office, but when possible, the procedure is performed within a couple days of diagnosis.