Hemorrhoids are swollen varicose veins in the anal canal. The anal canal measures only about 2 inches in length and extends from the rectum and ends at the the anal opening. It is lined by anal pads. There are normally three anal pads, two on the right and one on the left side of the anal canal. The anal pads are filled with veins and arteries and covered by anal mucosa, and act like flexible cushions that seal the anal canal. These cushions are supported by anal ligaments that are attached to the muscular wall of the anus. Normally these cushions remain in place, but if the anal ligaments are weak, or the anal veins swell and become varicose, they may slide down the anal canal to become hemorrhoids.

Hemorrhoids are due to several causes and are equally common in men and women.

Hemorrhoid Causes

Hemorrhoids tend to run in families, probably due to hereditary laxness of the supporting ligaments that hold the anal pads in place. This allows the anal cushions to slide down the anal canal. Hemorrhoids in this group can occur as early as the late teens.

Pregnancy. Due to pressure on the pelvic veins by the unborn fetus, the anal veins become distended and are prone to prolapse, and also thrombosis.

As people age, they can develop hemorrhoids because of stretching and laxity of the ligaments and tissues supporting the anal cushions, allowing the hemorrhoids to prolapse and slide down the anal canal.

Constipation can cause hemorrhoids, because patients have to strain to pass a bowel movement. This again increases the pressure in the anal cushions causing them to swell and making them more likely to prolapse.

There are several kinds of hemorrhoids that are commonly referred to:

Internal Hemorrhoids

These are the hemorrhoids caused by increased pressure and varicosity of the anal cushions. They are covered by anal mucosa, and can become the size of a large grape. They start life in the anal canal, but as they enlarge they easily slide down the anal canal and protrude from the anus. Once there, they require manual reduction, that means that they need to be pushed back inside after bowel movements. Eventually they may thrombose, ulcerate, or strangulate.

External Hemorrhoids

An external hemorrhoid is that part of the hemorrhoid that is covered by anal skin as opposed to the anal mucosa of the internal hemorrhoid. They belong outside the anal canal, and can vary in size. Some are so large that they completely surround the anal opening. They are common after pregnancy and require laser treatment because they are a constant irritant, causing itching and difficulty in cleansing of the area. Last but not least, they are unsightly and embarrassing.

Bleeding Hemorrhoids

Because the varicose hemorrhoidal veins are so thinly covered inside the anus, even the slightest irritation or trauma will cause the hemorrhoids to bleed. This can cause embarrassing staining of the clothing at the most inappropriate times. Chronic bleeding hemorrhoids will cause iron deficient anemia, and need to be treated with laser therapy.

Hemorrhoids of Pregnancy

Hemorrhoids often arise during pregnancy as a result of pressure on the pelvic veins causing swelling and stasis in the hemorrhoid veins.

Thrombosed External Hemorrhoids

Occasionally, increased pressure in the blood vessel of an external hemorrhoid will cause the vein to balloon and burst. This produces a painful swelling, sometimes to more than an inch in size, and in some cases, particularly in pregnancy, there may be more than one. The increase in pressure can be due to straining when lifting, diarrhea, pregnancy or constipation. Thrombosed hemorrhoids need to be treated urgently.

Prolapsed Hemorrhoids

As hemorrhoids progress and get larger they start to to slide and protrude from the anus, until eventually they are always prolapsed. The anal mucosa produces a slimy mucus that is necessary to lubricate the anal canal. This mucus is normally absorbed by the body, but if the hemorrhoid is constantly outside of the anus, there is constant mucus drainage into the underwear. It is amazing how long patients will put up with bleeding and mucus drainage, when prolapsed hemorrhoids are so easily removed with the laser. Not only are the drainage and bleeding so miserable, there is also a danger of ulceration and eventually strangulation.

Ulcerated Hemorrhoids

Because prolapsed hemorrhoids are outside of the anus, they can easily become damaged and eventually ulcerated. This is extremely painful, and the ulcerated hemorrhoids produce an unpleasant odor and problems with cleanliness.

Strangulated Hemorrhoids

When hemorrhoids prolapse out of the anus, sometimes the sphincter that controls the bowel movement goes into spasm and tightens around the hemorrhoids like a noose. This prevents the hemorrhoids from returning into the anal canal, at the same time cutting off the blood supply. This is an extremely painful condition that requires urgent treatment.

Grade I Hemorrhoids

This is the very beginning of the life of a hemorrhoid. The symptoms are itching, bleeding, constipation and discomfort. At first they can be treated with stool softeners, and baby wipes instead of toilet paper. Eventually these hemorrhoids will progress to grade 2 and require laser treatment

Grade II Hemorrhoids

are larger and begin to protrude through the anal opening. They will usually go back on their own, or as they become larger they will need to be pushed back after bowel movements. These hemorrhoids are suitable for laser removal.

Grade III Hemorrhoids

In this advanced stage of hemorrhoids, the hemorrhoids prolapse out of the anal canal and swell after each bowel movement. They require manual reduction and need to be treated.

Grade IV Hemorrhoids

In this stage the hemorrhoids are just always there, and often swell and cause pain. Some of the symptoms are, bleeding, mucus drainage, and severe pain if the blood inside the varicose hemorrhoidal vein clots. These hemorrhoids often require urgent treatment by removal with the CO2 laser as an outpatient under IV sedation.

Treatment of Hemorrhoids

Non Interventional

Minor hemorrhoids can be treated conservatively. A diet with adequate roughage is essential and stool softeners such as Metamucil are a good addition. Most of us are too rough when it comes to cleansing the anal area. The skin around the anal area is as sensitive as the whites of our eyes and should be treated as such. So rough wiping with toilet paper should be avoided. We suggest the use of baby wipes to clean the area gently after a bowel movement, and then dry thoroughly by gently patting the area with toilet paper. A hair dryer does an excellent job if there is any irritation. We like Desinex powder to keep the area dry.

There are many over the counter creams such as preparation H, which can be very helpful, but care must be taken, as they can cause an allergic reaction of the anal skin. Cortisone ointments are often prescribed, but long time use will cause the skin to become thin and easily damaged.


Internal hemorrhoids can be treated using an instrument that places a rubber band around the base of smaller hemorrhoids. The band is tight enough to cut off the blood supply to the hemorrhoid. The hemorrhoid and band drop off after about two weeks.

Disadvantages to this treatment are, that it is difficult to place the band correctly and the procedure is uncomfortable. Only smaller internal hemorrhoids can be treated because external hemorrhoids cannot be banded.

Infrared coagulation (IRC)

IRC is used only on internal hemorrhoids, and requires numerous office visits for treatment. In our experience the procedure is uncomfortable and any help it provides only lasts about three months.

Surgical Treatment

Unfortunately most hemorrhoid surgeons insist on using a 19th century method of treating hemorrhoids called a Milligan – Morgan hemorrhoidectomy, first described in the Great Britain. This method requires removal of the hemorrhoids with a surgical knife and scissors whilst the patient is under general intubation anesthesia, lying on their stomach. That is full anesthesia with a tube placed into the lungs so that the anesthesiologist can breathe for the patient. This places considerably increased risk on older patients and those with heart or lung disease as it is much harder to breathe whilst lying prone.

It is a one size fits all surgical operation during which the internal and external hemorrhoids are removed with surgical scissors, in one piece, without taking into consideration various ways in which hemorrhoids can present themselves. The wounds are then sutured closed, causing further pain.

Because of the amount of damage to the tissues from surgical excision, recovery is slow and bowel movements are extremely painful. Patients require more narcotics, complicating the situation because narcotics cause constipation. It can take two weeks or more for patients to return to work, or other activities, such as child care, and physical exercise.

There are more complications after surgical excision, particularly urinary retention (Inability to urinate). In some studies, up to ten percent of patients require post operative catheter placement, whereas our rate is less than one half of one percent.

This is the way I was trained to treat hemorrhoids.

Laser Hemorrhoidectomy

I felt that that there had to be a minimally invasive way to treat hemorrhoids that not only was less painful, but that worked, and only required one treatment. When medical lasers became available, I saw an opportunity to achieve my goal. I felt that if they are safe for eye surgery, they would work for hemorrhoids.

How Our Laser Treatment Works

A laser beam is created by passing a strong electrical current through a sealed tube containing one of several gases. We use a Carbon Dioxide (CO2) laser so the gas in the tube is CO2. The electrical current excites the CO2 until it produces a colorless narrow beam of light. In order for the surgeon to be able to see the laser beam a red light is added to it. The laser beam now passes through a series of mirrors to the hand-piece that the surgeon uses.

The reason that we use a CO2 laser is that different gases produce beams with varying properties. Our laser uses two settings, a narrow beam for cutting and a wide angle beam for vaporizing. In the cutting mode, the beam seals and coagulates as it divides the tissues, which is much gentler than surgical scissors, and the beam only penetrates a small fraction of the tissue, so it does not damage underlying structures. In the vaporizing mode, the laser beam simply vaporizes the hemorrhoid, leaving a small dry scar. This cannot be done with the surgical scissors. For this reason hemorrhoids can be treated with the laser, more completely but with less tissue damage.

The Procedure

When we laser hemorrhoids, it is an outpatient procedure. The patient is given enough intravenous (IV) sedation so that they are comfortably asleep and feel no pain. For this reason we can treat patients with even the most complicated risk factors safely. The patient is treated lying on their back, so that breathing is unassisted and is easy and safe.

With the patient lying on their back and breathing easily under IV sedation, the anal area is injected with long acting local anesthesia so that when they awaken, they feel no pain. The larger hemorrhoids are removed using the laser in cutting mode. The laser seals as it cuts, so stitches are rarely used. Because the laser beam is so small, there is an excellent view of the hemorrhoid, and as a result of this there is no risk of damaging the muscles that control the bowel movements. For this reason, we have never had a patient who could not control stool or gas after laser hemorrhoidectomy.

After lasering the larger hemorrhoids, smaller hemorrhoids are now vaporized, with the laser in the vaporizing mode. This produces a small, painless scar, which heals quickly. If we vaporize a larger internal hemorrhoid we might band it first to control possible bleeding.

Sometimes the internal and external hemorrhoids are separated by a bridge of anal skin. In this case, we will vaporize the internal hemorrhoid with the wide angle laser beam and excise the external hemorrhoid with the cutting beam. This gives us a lot of flexibility, which is not available with the surgical excision approach.

As you can see, the procedure is safer using IV sedation and local anesthesia with the patient lying comfortably on their back, than general intubation anesthesia with patients lying on their stomachs limiting their ability to breathe normally.

When comparing laser removal to traditional surgical excision of hemorrhoids.
1, laser treatment is more effective,
2, with less tissue damage,
3, has the ability to remove more of the hemorrhoids,
4, and because of the decreased tissue damage there is less pain,
5, and a speedier recovery.
6, and most of all, fewer complications.

After Surgery

Patients awaken quickly, without nausea or headache, and a feeling of well being. There is no pain, as the long acting local anesthesia is now working.
The patient is returned to their family member or friend, as, because of the sedation patients cannot drive themselves home. Once home, patients can take prescribed pain medication if necessary. Any discomfort is usually controlled by sitting in warm water as long as they wish. A cup of epsom salts added to the water is very soothing. We suggest stool softeners in the post treatment period. The first bowel movement can be painful, and it helps to have it in a sitz bath, which is a small bowl that can be bought at any pharmacy cheaply, and fits on the toilet bowl. A teaspoon of Epsom salts can be added to the water for added comfort. The healing area should be cleansed by dabbing with a baby wipe, or using a plastic squirt bottle that we provide, that can be filled with warm water.

Healing is rapid, and most patients are back to normal, and can return to work in three to five days, depending on the severity of the hemorrhoids. A follow up appointment is usually not needed unless the patient has questions.


Except in very rare occasions, the hemorrhoids will not come back. We have performed over three thousand laser hemorrhoid procedures, and it is very rare for us to see a recurrence. We calculate less than one in one hundred.

Light Bleeding may occur, but no more than ten days after treatment, and never enough to cause alarm. After any type of surgery, a secondary hemorrhage (bleed) can occur, usually on about the tenth day after the procedure. We see approximately one a year, and out of three thousand patients, only two have required blood transfusion, and both recovered uneventfully.

Urinary retention (inability to pass urine) rarely occurs, and is almost always in men with a history of prostate disease. We maybe see two a year who require catheterization out of 750 patients.

We do not know of any patient who has lost the ability to control stool or gas after laser hemorrhoid treatment.

We also do not know of any patient who has suffered narrowing of the anus.

Infection does not occur after laser hemorrhoid treatment, so antibiotics are never necessary.

No patient has died or suffered a major postoperative complication, requiring hospitalization, as a result of the laser hemorrhoid procedure.

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