External hemorrhoids

What is an external thrombosed hemorrhoid?

An external thrombosed hemorrhoid is a misleading name. It is not a hemorrhoid but a thrombosis of one or more small veins from the skin around the anus. There are no internal hemorrhoids at the periphery of the anus(in normal circumstances), unless internal hemorrhoids slide outside the anal canal ore protrude during straining when passing stools.

Due to thrombosis (blood clot in a blood vessel), venous blood accumulates upstream of the clogged blood vessel. The accumulation of blood in the skin of the anal rim stretches the skin, stimulating the nerves and causing acute pain.

Acute straining accompanied by pushing (ex; childbirth) or constipation can be the cause of an external hemorrhoid.

External hemorrhoids mainly affect young patients. The average age is 36 years.

(Oh C Acute thrombose external hemorrhoids Mi Sinai J med 1989; 56 : 30 -32)

External thrombosed hemorrhoids are identified as a painful hard bluish swelling at the edge of the anus.

Without treatment, the pain more often improves after 2-3 days and usually disappears after 7-10 days. The blood finds a way to bypass the clogged vessel and the swelling and the pain regresses or due to pressure, the skin erodes followed by perforation and bleeding. This reduces pressure on the skin and reliefs the pain.

If the externally thrombosed hemorrhoid has been present for several days and the pain decreases, conservative pain management is attempted in the acute phase until the swelling spontaneously disappears.

Sometimes a residual skin tag remains at the edge of anus, after the swelling of the skin from the external thromboses hemorrhoid recedes.

In most cases, skin tags are not symptomatic. Skin tags can be removed if they are the cause of hygienic or aesthetic problems.

See surgical procedure : Removal of skin tags

Regardless of the applied treatment, recurrences of thrombosed hemorrhoids around the anus are frequent.

– High fiber diet and hydration.

– Laxative if constipation.

→ Ex: Lansoyl®, Movicol®, Dulcolax®…

– Sphincter relaxant cream

→ Ex: Rectogesic® nitrate-based magistral preparation 0,2%,

diltiazem-based cream 2%

– Analgesic cream  

→ Ex: Xylocaïne® cream 5% – 2%

– Medication :

→ Flavonïde ( Daflon® depending on the regimen)

– Analgesic:

→ Paracetamol (Dafalgan forte® 1gr 3-4x /jr)

→ Anti-inflammatory (Brufen® 600 2-3x /day,  Cataflam®)

→ Morphine (Tradonal® retard 50 mg (4-6x/day) if necessary

If the pain is too intense, the hemorrhoid can be incised and the blood clot removed or the thrombosed venous pack can be excised under local or general anesthesia.

See surgical procedure : Incision / excision external hemorrhoid

Postoperative complications:

→ Bleeding 0,3%

 → Abscess/fistula 2,1%

 → Recurrence of an external hemorrhoid 6,5% à 22 month 

(Jongen J Excision of thromboses external hemorrhoid une local anesthesia: a retrospective évaluation  of 340 patients Dis Colon Rectum 2003; 46:1226 – 1231)