History of research of hemorrhoids is a history of one great mistake        

                         History of treatment of hemorrhoids is history of needless invasive treatment.

Diagnosis & Treatment of Hemorrhoids

Gastroenterology May 2004 volume 126 number 5
American gastroenterological association technical review on the diagnosis and treatment of hemorrhoids
Robert D. Ma doff * [MEDLINE LOOKUP]
James W. Freshman † * [MEDLINE LOOKUP]
Hemorrhoids are a common condition, but their true prevalence is unknown. Most patients and many physicians tend to attribute any anorectal symptom to hemorrhoids . Furthermore, anal cushions are normal structural components of the anal canal that are present from infancy.1 Despite their confusing epidemiology, it is important for gastroenteritides, surgeons, and primary care physicians alike to be able to accurately diagnose hemorrhoids and offer a rational, effective treatment plan.
Hemorrhoids are found in the sub epithelial space of the anal canal. They consist of connective tissue cushions surrounding the direct arteriovenous communications between the terminal branches of the superior rectal arteries and the superior, inferior, and middle rectal veins. Anal sub epithelial smooth muscle arises from the conjoined longitudinal muscle layer, passes through the internal anal sphincter, and inserts into the sub epithelial vascular space. There, the smooth muscle suspends and contributes to the bulk of the hemorrhoidal cushions. The cushions contribute approximately 15%-20% of the resting anal pressure Perhaps more importantly, they serve as a conformable plug to ensure complete closure of the anal canal. Most people have 3 of these cushions, but cadaver studies have shown that the so-called typical right anterior, right posterior, and left lateral configuration of the cushions occurs only 19% of the time.
Symptoms attributed to hemorrhoids include bleeding, protrusion, itching, and pain For the most part, external hemorrhoids are asymptomatic unless they become thromboses, in which case they present as an acutely painful perianal lump. Persisting skin tags after resolution of the thrombosis can lead to problems with hygiene and secondary irritation.
Most hemorrhoidal symptoms arise from enlarged internal hemorrhoids . Abnormal swelling of the anal cushions, stretching of the suspensory muscles, and dilation of the submucosal arteriovenous plexus result in the prolapse of upper anal and lower rectal tissue through the anal canal. This tissue is easily traumatized, leading to bleeding. The blood is typically bright red due to the arterial oxygen tension caused by arteriovenous communications within the anal cushions. Prolapse of the rectal mucosa leads to deposition of mucus on the perianal skin, causing itchiness and discomfort.
The pathogenesis of the enlarged, prolapsing cushions is unknown. Many clinicians believe that inadequate fiber intake, prolonged sitting on the toilet, and chronic straining at stool contribute to the development of symptomatic hemorrhoids, yet rigorous proof of such beliefs is lacking. Other factors have also been proposed, including constipation, diarrhea, pregnancy,, and family history.5 None of these have been rigorously proven, although 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids.
Multiple studies have shown elevated anal resting pressure in patients with hemorrhoids when compared with controls5; voluntary contraction pressure is unchanged. Whether the elevated resting pressure is caused by or due to enlarged hemorrhoids is unknown, but resting tone becomes normal after hemorrhoidectomy.  Ultra slow pressure waves are more common in patients with hemorrhoids, but the significance of the waves is uncertain.
The epidemiology of hemorrhoids has been studied using a number of approaches, each of which has shortcomings. Accordingly, the data must be interpreted with caution. Population-based surveys rely on self-reporting of a condition with symptoms that are nonspecific; moreover, a physician observer does not validate these supposed diagnoses. Hospital discharge data are more reliable in this regard but still remain imperfect; it is likely that most patients with a diagnosis of hemorrhoids at discharge have not in fact undergone a directed anorectal examination. Similar criticism may be leveled at physician visit data; a complete evaluation, including anoscopy, cannot be assumed to have taken place, particularly if the data are from primary care providers. Hospital-based proctoscopy studies show prevalence rates of up to 86%, even though many of their patients are asymptomatic.
Despite these caveats, the community-wide prevalence of hemorrhoids in the United States is reported to be , with a peak prevalence occurring between 45 and 65 years of age. Increased prevalence rates are associated with higher socioeconomic status, but this association may reflect differences in health-seeking behavior rather than true prevalence. Population-based surveys suggest that the prevalence of hemorrhoids decreased in both the United States and United Kingdom during the second half of the 20th century Hemorrhoids are frequently seen in patients with spinal cord injury.