The primary disease process affecting external hemorrhoids is
thrombosis. The mainstay of treatment is excision. It is important
to remember that the excision is to alleviate or palliate the pain. The
natural history of an untreated thrombosed external hemorrhoid is
to rupture and spontaneously evacuate the clot or to resorb the
clot over time. Therefore, treatment should give the maximum amount
of pain relief with the least chance of complications. To make this
decision it will be important to obtain a good history of the length
of the pain, how severe it is, and whether there has been improvement.
It is important to perform a physical examination to rule out prolapsed
grade IV internal hemorrhoids, perianal abscesses, and other perianal
External hemorrhoids fall into three main groups: left lateral,
right anterior, and right posterior (Figure 57-1). They are covered
with anoderm and visible on the outside of the anal canal. They are
composed of a venous plexus mixed with connective tissue. They drain
into the middle and inferior rectal veins that terminate into the
internal iliac and femoral veins, respectively. External hemorrhoids
do not prolapse like internal hemorrhoids. They engorge and thrombose.
It will not benefit the patient to try to reduce an external hemorrhoid
since their normal location is mostly outside the anal canal and
reduction will not remove the clot. External hemorrhoids are never
covered with mucosa. The overlying skin may appear to look shiny,
swollen, gangrenous, or like an orange peel mimicking the look of
The position of the three main groups of external hemorrhoids.
The patient usually complains of a history of the sudden onset
of pain and swelling. The exact cause of thrombosed external hemorrhoids
is unknown. It is probably related more to straining with lifting,
jogging, or bicycling than chronic constipation. This explains why
this problem occurs more often than internal hemorrhoidal disease
in a younger age group.
External hemorrhoids can be diagnosed when a patient complains
of a sudden onset of pain and swelling, usually with no bleeding.
The physical examination will reveal a tensely swollen area covered
with anoderm. The swelling will be visible by gently spreading the
buttocks and inspecting the area near the anal canal. They have
a bluish coloration, especially in patients with little skin pigmentation,
and almost no redness. The swelling is abrupt, like placing a marble
under a sheet and tucking in the edges. This differentiates the
appearance of a thrombosed external hemorrhoid from the appearance
of an abscess that would have erythema and gently sloping sides from
The primary indication for the excision of a thrombosed external
hemorrhoid is pain. The excision should occur as soon as possible
from the onset of pain and not after the fourth day.1 The
pain should become tolerable in the normal ...