Procedure for Prolapsing Hemorrhoids

By Paul C. Shellito, M.D.
Content provided by the Faculty of the Harvard Medical School


I have to have the PPH procedure done for internal hemorrhoids, and am wondering about the recovery time and the actual time it takes to do the procedure. If I am given a local, will it be an epidural or something else? What is the usual procedure and what can I expect?


Hemorrhoids are lumps or masses of tissue in the anus that contain enlarged blood vessels. Hemorrhoids may be inside the anal canal ("internal hemorrhoids"), where they primarily cause the symptom of intermittent bleeding, usually with bowel movements. They may also lie just outside the anal canal ("external hemorrhoids"), where they primarily cause symptoms of swelling and sometimes discomfort, which may occur intermittently when the hemorrhoids become especially irritated. Many patients have both internal and external hemorrhoids.

Hemorrhoids are not dangerous, so treatment for hemorrhoids is almost always optional. Often minor symptoms of hemorrhoids can be relieved with treatment at home (fiber and warm water soaks). Nevertheless, if there are symptoms of rectal bleeding, it is important for the patient to see his or her doctor for an examination. When hemorrhoid symptoms are persistent and bothersome, more definitive treatments are available. The choice of treatment depends upon the size and location of the hemorrhoids.

For hemorrhoids that are small to medium sized, and primarily internal (which primarily cause the symptom of bleeding), office treatment of hemorrhoids can be carried out, including rubber band ligation, infrared coagulation, electrocoagulation, freezing therapy, and injection sclerosis.

For patients who have quite large hemorrhoids, or if there is prominent external hemorrhoids (which primarily cause the symptoms of swelling, discomfort, or difficulties keeping the anal area clean), office treatments are not applicable. In that case, hemorrhoidectomy (surgically removing the hemorrhoids) is the best treatment, if treatment is desired.

A new operation called "stapled hemorrhoidopexy," or "procedure for prolapsing hemorrhoids" (PPH) is available for some types of hemorrhoids, . In this procedure, a surgical stapling device is used to remove a ring of tissue just above the hemorrhoids, in order to pull them back up inside the rectum and reduce symptoms (this is done under anesthesia, as an outpatient). The advantage of stapled hemorrhoidopexy is that it is less painful than traditional surgery, and unlike hemorrhoid ligation it does not require multiple treatments. Like hemorrhoid ligation, however, it is not applicable if there are prominent external hemorrhoids.

Since it is a relatively new procedure, the long-term effectiveness of stapled hemorrhoidopexy is not known. Experience so far, however, has suggested that it works well, for the right type of hemorrhoids. The procedure usually takes about a half hour. It is usually done under general anesthesia, but can also be done under local, spinal, or epidural anesthesia (usually this would be a decision that you would make with the anesthesiologist, after discussing the options with him or her on the day of the surgery). After stapled hemorrhoidopexy, most patients have moderate discomfort for less than a week, and can usually return to work anywhere from a day or two, to seven to 10 days after surgery (it would be safe to return to work whenever you feel up to it).

Serious complications are rare after any hemorrhoid treatment. Surgery of any type has a risk of infection, bleeding, or drug or anesthesia reactions, but these are very unusual. Scarring and narrowing of the anal canal ("stenosis," or "stricture") is a very small risk with surgery or stapled hemorrhoidopexy. There is a remote risk of serious infection or bleeding after hemorrhoid ligation. There is a small risk of bleeding, and a very remote risk of bowel perforation, or rectovaginal fistula (an abnormal connection between the rectum and vagina) after stapled hemorrhoidopexy. Rarely, patients can have inexplicable prolonged rectal discomfort after stapled hemorrhoidopexy.

Sometimes men have difficulty urinating after any rectal operation ("urinary retention"), probably because of muscle spasm around the bladder in response to the discomfort of surgery. In rare cases, this requires temporary placement of a catheter in the bladder, especially if the man has an enlarged prostate gland. Irritation and stretching of the anal sphincter muscle during surgery or stapling can occasionally cause minor incontinence (difficulty controlling gas, or perhaps a little seepage if the stool is loose), but this is usually temporary, if it occurs at all. Recurrence of hemorrhoids is a risk after any treatment, but this occurs in less than 10% of patients.

Last Annual Review Date: 2008-02-22T00:00:00-07:00 Copyright: Copyright Harvard Health Publications

Reference: Digestive System section on Better Medicine