Hemorrhoids – external

The term ‘external hemorrhoids’ should probably be stricken from the vocabulary.  It is just too confusing.  Unlike internal hemorrhoids (actual hemorrhoids), so-called external hemorrhoids are really just bits of redundant skin at the outer edge of the anal canal (anal verge).  External hemorrhoids should really just be referred to as ‘skin tags’.  These tags may be caused by anal inflammation such as an anal fissure.  When a skin tag is the result of an underlying anal fissure, the tag is referred to as a ‘sentinel pile’, indicating that it is a ‘sentinel’ or sign of deeper trouble within the anal canal (the fissure).  When a skin tag/sentinel pile is tender, it usually means that the underlying anal fissure is active.  In such cases, the fissure needs to be dealt with.  Many patients will come to the Clinic to have their painful external hemorrhoid removed, thinking that this will solve their problem.  In reality, what they are suffering from is an anal fissure inside the anal canal and an associated painful and swollen sentinel pile on the outside.  They think that the sentinel pile is a hemorrhoid.   Just cutting off the painful sentinel pile will not solve the problem, it may just come back if the fissure is not dealt with and the pain of the fissure will persist even if the sentinel pile is removed.

In patients who just have so-called external hemorrhoids or skin tags that are just in the way and a nuisance and not necessarily painful, excision of the tags under local anesthetic is the best way of getting rid of them.  Contrary to what many patients are told, rubber band ligation inside the anal canal will almost never get rid of external skin tags and banding should not be done for this purpose.  Also, placing a rubber band around a skin tag directly is not an appropriate treatment since it would be far too painful given that a tag is covered by sensitive skin.  Rubber banding is reserved for inside the anal canal and low rectum, where the lining is far less sensitive, and should only be used to treat internal hemorrhoids.  Excision of external tags under local anesthetic is a simple procedure that is well-tolerated and can make an enormous cosmetic difference.

By the way, an internal hemorrhoid that prolapses through the anal canal and is visible on the outside is called a prolapsing internal hemorrhoid.  It is not an external hemorrhoid.  Prolapsing internal hemorrhoids are good candidates for banding providing they are not too large.

© Pezim Clinic, Vancouver, British Columbia, Canada