0002-9270/89/8405-0483THE AMLRICAN JOURNAL OF GASTROENTEROLO«Y

Copyright ® 1989 by Am. Coll. of Gastroenterology

Vol. 84. No. 5. 1989Printed in U.S.A,

Direct Current Electrotherapy of Internal Hemorrhoids:An Effective, Safe, and Painless Outpatient Approach

Daniel A. Norman, M.D., F.A.C.P., Ronald Newton, B.S., and Glenn V. Nicholas, D.C.University of Nevada. School of Medicine. Reno. Nevada, and Barton Memorial Ho.spiial. South Lake Tahoe. California

Hemorrhoid disease is one of the most frequentlyoccurring, disahling conditions of man. We report theresults of 120 patients with symptomatic internal andmixed hemorrhoid disease treated with direct current(d.c.) via a dual-tipped disposahle needle prohe (nega-tive electrode). Evaluation and treatment utilized anoperative anoscope which visualized one-eighth of theanal canal. Five hundred ninety segments revealed he-morrhoid disease (grade I = 114, 2 = 222, 3 = 178, 4= 76). One or more segments (highest grade) weretreated per office visit. Symptoms, frequency, and meannumber of treatment applications per patient for com-plete symptom resolution were: hieeding, 85%, 4.0;protrusion, 58%, 3.9; pain, 52%, 3.6; and pruritus, 49%,3.9. Ahlation of hemorrhoid disease grade was directlycorrelated with milliampere current and time of appli-cation. No major complications occurred. All patientswere successfully treated and remained symptom-freeat a mean duration of follow-up of 23 months. Directcurrent electrotherapy is an effective, painless, and safeoutpatient treatment approach to all grades of internaland mixed hemorrhoid disease.

INTRODUCTION

Hemorrhoid disease is one of the most frequentlyoccurring and disabling conditions of mankind. Be-cause of eonlroversy in the definition of "hemorrhoids"(1)., the consensus of the Advisory Panel of the Foodand Drug Administration will be used in this text:"Hemorrhoids are abnormally large or symptomaticconglomerates of blood vessels, supporting tissues, andoverlying mucous membrane or skin of the anorectalarea" (2).

It is estimated that one-third of the population of theUnited States has symptomatic internal hemorrhoids(3) with an incidence of 50% al age 50 yr (4). Further,up to 80% of both sexes will have the symptoms ofhemorrhoids at some time in their lives (5). Patientsfrequently postpone examination because of concernof pain associated with a particular treatment modality,hospitalization, cost, and time of disability. Such a delay

Received July 19, 1988: revised Dec. 9. 1988: accepted Dec. 19.19SS.

in evaluation may lead to progression of the hemor-rhoid disease, or late diagnosis of serious colorectalproblems.

Direct current (d.c.) electrotherapy of hemorrhoiddisease represents an alternative therapeutic approachthat off-sets the above concerns. This method v̂ 'as firstutilized in 1867. A comprehensive review of the subjectwas published by Wilbur E. Keesey. M.D., in 1934 (6).However, this approach to hemorrhoid disease was notadvanced, nor has it enjoyed wide attention in themedical community.

The following represents the results of a study utiliz-ing d.c. electrotherapy in the treatment of hemorrhoiddisease. In addition, advancement in technology is pre-sented.

METHODS

SubjectsOne hundred twenty consecutive patients with symp-

lomatic hemorrhoid disease completed d.c. electro-therapy. All underwent historical review, and visualand digital examination. No bowel preparation, oral orparenteral medication therapy, was required. Digitaland anoscopy were performed with an anesthetic jellylubricant. Anoseopy was performed with the Hinkle-James rectal speculum with an operative port exposingone-eighth of the circumference of the anal canal. Sub-jects with source other than hemorrhoid disease ac-counting for their symptomatology were excluded fromthe study.

AnoscopyAt anoscopy. eight segments were visualized with the

patient in the right lateral position. Segment 1 is on thepatient's left, and additional segments are numberedclockwise. Internal hemorrhoid disease was graded ac-cording to the method of Banov et al. (I): grade I. tuftof hemorrhoidal tissue without prolapse through theanal canal; grade 2. prolapse with straining and spon-taneous retraction: grade 3. prolapse with strainingrequiring manual reduction; and grade 4. nonreducibleprolapse. Mixed hemorrhoid disease occurs when avascular communication of diseased internal to theexternal hemorrhoid vasculature is present.

482

Mav 1989 DC ELECTROTHERAPY OF INTERNAL HEMORRHOIDS 483

Direct current electrotherapy instrumentationThe current generator was developed to provide

smooth d.c. current from 110 V a.c. The delivery ofd.c. current to the hemorrhoid is by a probe handle andsterile disposable dual probe tip. The handle was de-signed for single hand application and incorporatesmiliiampere and time display and controls for timerreset, initiation and cessation of current flow to theprobe tip, and increase or decrease of current flow.Probe tips may be rotated in the handle for ease ofapplication. The probe is the negative electrode andgrounding pad the positive electrode {Microvasive Inc.,Watertown, MA).

Direct current electrotherapy techniqueWith the patient in the right lateral position, the

grounding pad was positioned securely, generally be-neath the dependent thigh. The probe tip assembly wassecured in the treatment handle in the horizontal posi-tion for left and right disease and vertical position foranterior and posterior disease. The hemorrhoid to betreated was isolated in the anoscope operative post. Theprobe tip was placed on. but not inserted into, theuppermost portion of the hemorrhoid. in the longitu-dinal axis of the vessel and at a slight angle to the analcanal (Fig. I.). Inquiry as to the sensation of the prot>e

Fi<;. I. Direct current probe treatment position on uppermostposition of hemorrhoid. in the longitudinal axis of the vessel, and ata slight angle lo ihe anal canal.

tip by the patient was made, and if sensation waspresent, the probe tip was repositioned. The currentwas then initiated and raised to 2 mA. The probe tipthen was advanced 0.5 cm into the hemorrhoid vessel.Further penetration is prevented by covering insulation.Current was increased over a 1- to 2-min period to amaximum of 16 mA or to patient tolerance. A rapidincrease in current may be sensed as a dull ache, oftenavoided by a more gradual increase. Individuals notingdiscomfort at less than 16 mA were treated at a lowermillianiperage. Upon completion of treatment, the cur-rent was slowly decreased to zero by continuous depres-sion of the appropriate control, after which the probeand anoscope were removed.

One or more hemorrhoid segments were treated perofUce visit. The highest grade(s) of disease was treatedfirst. If, on evaluation, a previously treated segmentrevealed any grade of hemorrhoid disease, additionaltreatment was applied and the data incorporated intothat segment. Patients returned for evaluation of priorand additional treatment after 10-14 days.

Completion of the treatment was defined as a com-plete anoscopy without the presence of hemorrhoiddisease (all segments grade 0) in 99 patients and reso-lution of all symptoms with residual grade 1 hemor-rhoid disease in one or more segments in 21 patients.

Follow-up data regarding symptomatology was ob-tained by direct contact. If symptoms suggestive ofhemorrhoid disease were elicited, anoscopy was per-formed for diagnosis. Asymptomatic patients did notundergo anoscopy at follow-up.

Student's / test was used for statistical evaluation ofdata comparing hemorrhoid grades, and values wereconsidered to be significantly different with p < 0.05.Data are expressed as mean ± SD (range).

RESULTS

One hundred twenty patients (74 male 46 female),mean age 48 (range 21-86) yr, underwent evaluation

TABI.L" I

Hemorrhoid Disease Grade. Symptom Duration, and Therapy Prior to Direct Current Therapy

HemorrhoidDisease

No. of Patientswilh Grade as

Maximal Disease

No. of Hem.SegmentsTreated

Duration ofSymptoms

(mo)*

Prior Therapyt

Surgeryl:No./%

Medicat§No./%

Grade IGrade 2Grade 3Grade 4

Total

II264637

120

11422217876

590

100 ±96101 ± 164124± 142131 ± 105

I I9± 134

1/94/156/134/11

15/12.5

8/7317/6536/7824/65

85/73

* Months, mean ± SD.t Docs not include injection sclerotherapy 2. cryosurgery I, or rubberband ligation 1.% Surgical hemorrhoidcctomy.§Topicai (prescription and OTC) cream and/or suppository and/or stool bulking agent.

484 NORMAN et al. Vol. 84, No. 5. 1989

for symptomatic hemorrhoid disease and treatmentutilizing d.c. electrotherapy.

The mean duration of symptoms was 119 (rangedto 804) months. The mean number of months of symp-toms correlated directly with grade of hemorrhoid dis-ease; however, significant overlap between duration ofsymptoms and hemorrhoid grade exists (Table 1). Sur-gical hemorrhoidectomy had been performed in 12.5%of patients prior to d.c. current therapy and was per-formed with similar frequency in all hemorrhoid gradegroups. Medical therapy, including prescription topicalcream and/or suppositories and over-the-counter prep-arations, including stool-bulking agents, had been usedby 85 patients and was similar for each grade. Long-standing hemorrhoid symptoms did not require a trialof topical therapy prior to d.c. current treatment. Symp-toms at presentation and number of treatment appli-cations required for complete resolution of these symp-toms are presented in Table 2. The most commonsymptom was rectal bleeding in 85%. followed by in-ternal hemorrhoid protrusion through the anal canal(58%). pain (52%). and pruritus (49%). The meannumber of treatment applications for complete resolu-tion of these symptoms was 4.0. 3.9, 3.6, and 3.9,respectively.

A total of 590 segments with hemorrhoid diseasewere treated. With eight segments evaluated per patient,this represented a mean of 4.92 segments with hemor-rhoid disease. There were 114 grade 1. 222 grade 2. 178grade 3. and 76 grade 4 hemorrhoids. Twenty-six pa-

TABLK 2

Symptom ami Numher of Treatments Required for SymptomResolution in 120 Patients

Symptom Bleeding Protrusion Pain Pruritus

% Patients 85 58 52 49No. of treatments 4.0 ± 3.3 3.9 ± 2.9 3.6 ± 2.3 3.9 ± 2.5

{±SD) for symp-tom resolution

tients had grade 2. 46 patients grade 3. and 37 patientsgrade 4 as maximal involvement (Table 1). There wasa direct correlation of successful therapeutic resolutionof hemorrhoid disease grade severity with mean mil-liampere current and duration of application of d.c.electrotherapy (Table 3. p < 0.01. comparing eachhemorrhoid grade with another). On average, grade 1hemorrhoid disease required 9.5 mA for 7.9 min andgrade 4 required 12.2 mA for 14.3 min. More than onetreatment application to a diseased hemorrhoid seg-ment was required in about 20% of grades 1. 2. and 3hemorrhoid disease and in 33% of grade 4 disease(Table 3). In general, this reapplication was related topatient sensitivity with resultant low milliampere ap-plication at the initial approach to that segment. Mosthemorrhoid disease (78%) was successfully treated withone d.c. current application. The mean number oftreatments and retreatment requirements for eachhemorrhoid grade is shown in Table 3. A grade 1hemorrhoid required two or more treatment applica-tions in 23 of 114 segments (20%). Fifty-one applica-tions were applied to these 23 segments for a mean of2.22 retreatments in the retreatment group. Incorporat-ing the retreatment group into the total grade I seg-ments treated results in an overall requirement of 1.25treatment application for ablation of grade I hemor-rhoid disease.

All patients were successfully treated (ablation of allhemorrhoid disease in 99 patients and asymptomaticwith residual grade 1 hemorrhoid disease in one ormore segments in 21 patients, without visible scar tis-sue) and continued symptom free at a mean durationof follow-up of 23 (range 1-70) months. If a patientwas treated until asymptomatic (21 patients) with resid-ual grade I disease remaining, this residual was nottreated and. therefore, not incorporated into treatmentof grade 1 hemorrhoid disease. No major complicationsoccurred. One patient experienced a vasovogal episodewith syncope for 10 s immediately after d.c. currenttherapy without sequelae. He subsequently returned for

TABLE 31 /^DL-i:; J

Hemorrhoid Disease Grade, Total and Retreaiment Requirements for Resolution Utilizing Direct Current

Total Treatment for Resolution (±SD)*

HemorrhoidDisease mAt Mint mA X min

Mean No. ofTreatments toAsymptomatic

Retreatmcni Requirements

No. orSegments

No. of Treatmentsof Retreated

Segments

Mean No. ofRetreat nifnts of

Segment

Grade 1Grade 2Grade 3Grade 4

Total

9.5 ± 2.311.0 ±2.212.1 ±2.512.2 ±3.4

7.9 ± 4.69.4 ± 19.5

11.0 ±7.614.3 ± 10.6

76 ±5299 ±46

128 ± 76158 ± 99

1.251.281.381.80

1.36

23433825

129

20192133

22

5110410586

346

2.222.422.763.44

2.68

* Resolution to Grade 0: each grade compared to another significant at /? < 0.01.+ mA. milliampere.I Min. minutes.

May 1989 DC ELECTROTHERAPY OF INTERNAL HEMORRHOIDS 485

treatment without adverse effect. One patient experi-enced pain following treatment, relieved in hours witha sitz bath. Subsequent treatment was not associatedwith post-procedure pain.

DISCUSSION

An effective, safe, and generally painless procedurefor the outpatient treatment of internal and mixedhemorrhoid disease is presented. A therapeutic ap-proach initially performed in 1867 and described indetail in 1934, this application of d.c. current in thetreatment of hemorrhoid disease was virtually aban-doned as a modality directed at a very common debil-itating illness. Literature review reveals no recent pub-lications on, or references to. this approach to hemor-rhoid disease. Further, no instrumentation for theapplication of d.c. current to a diseased hemorrhoidcould be found on direct contact of major medical andchiropractic supply houses in the western United States.

An instrument incorporating safety and ease of op-erator use was developed. The generator was designedto provide direct current to a probe handle and tip fromllOV a.c. A controlled gradual delivery or withdrawalof current avoids the discomfort associated with suddencurrent change. Ease and comfort of treatment appli-cation is provided by a probe handle with data displayand controls which allow single-hand use. The abilityto rotate the probe tip in the handle offsets the need forsignificant rotation of the handle in treating differentareas of the anorectal canal. Sterile-disposable probetips offset the risk of potentially transmittable disease.

Patients were examined and treated in the rightlateral position (in contrast to the traditional left lateralposition used in sigmoidoscopic and colonoscopic pro-cedures) allowing for greater comfort while holding theanoscope. The bend of the knees of the patient in thisposition allows table space to rest the operator's leftelbow while holding the anoscope handle with the lefthand. In this study, the operative anoscop>e allowedvisualization of one-eighth of the anal canal circumfer-ence. The anal canal was, therefore, divided into eightsegments. Direct current electrotherapy was applied to590 hemorrhoid disease segments of 120 patients. Tra-ditionally, three primary (left lateral, right posterior,and right anterior) and two secondary (left posteriorand left anterior) positions of internal hemorrhoids aredescribed (4). Therefore, overlap occurred in anatomi-cal origin versu.s treatment localization of internalhemorrhoids in this study.

The mean number of hemorrhoid segments per pa-tient was about 5. Direct current electrotherapy wasdirected at the highest grade hemorrhoid first, with oneor more segments treated per office visit. Symptoms ofbleeding, hemorrhoid protrusion through the anal

canal, pain, and pruritus were resolved after treatmentof an average of four segments. Overall, a second ormore treatments of a particular segment was requiredin 22%. This was generally in patients intolerant ofhigher milliamperes of d.c. application. Low milliam-pere application requires a longer time of treatment.This group of patients resulted in a high variability oftreatment requirements. However, most diseasedhemorrhoids were successfully treated with a singletreatment application (78%).

Our initial experience was directed toward ablationof all diseased hemorrhoid segments. Later patientsunderwent treatment until asymptomatic, often leavinglow-grade hemorrhoid disease untreated. In that hem-orrhoid therapy is directed toward symptoms in thevast majority of patients, the latter approach seemsmost appropriate. Should symptoms recur, patients areencouraged to present for evaluation and additionaltreatment and are generally willing to do so.

No treatment failures were encountered. This mayrelate to our approach to our patient population regard-ing retreatment. Two grade 4 and one grade 3 hemor-rhoid required a total of six treatment applications toresolve to grade 0. Two grade 4. three grade 3. and onegrade 2 hemorrhoid required five treatment applica-tions. In general, symptoms improved with successivetreatments, and repeated visits were acceptable to thesepatients.

No major complications occurred in the treatmentof 590 diseased hemorrhoid segments. Minor compli-cations were noted in two patients. One patient expe-rienced a vasovagal episode with syncope for 10 s aftertreatment without apparent sequelae. He returned foradditional treatment without adverse effect. One pa-tient experienced rectal pain after treatment, whichresolved in hours with a sitz bath. This did not occurwith subsequent treatment. Direct current therapy ofhemorrhoid disease is a safe treatment approach.

Direct current in milliamperes and time applied wasdirectly correlated with disease grade (/? < 0.01 com-paring each grade to another). The milliampere-minute(mA X min) product may be used as a guide in treat-ment requirements. A grade 2 hemorrhoid, on average,has a mA x min of 99 (Table 3). This implies that 10mA applied will require about 10 min or 14 mA, 7 minof treatment. Other indicators of successful treatmentare a darkening of tbe treated segment, indicatingthrombosis, or a cessation of the popping sounds of gasrelease at the probe tip, indicating cessation of bloodflow at the treatment position.

Some patients noted a sense of dull nonlocalizedaching of the rectum at higher milliamperage. A de-crease of milliamperage resolved this complaint. Thus,correctly applied, this therapeutic modality achieved apainless ablation of internal and mixed hemorrhoid

486 NORMAN et ai

disease. This was possible for several reasons. First,somatic sensory innervation decreases through thetransitional zone of the anal canal and terminates atthe dentate line (4). Treatment above the dentate lineshould, therefore, be painless. Second, the probe tip isplaced on the hemorrhoid base above the dentate lineprior to current tlow, and the patient is asked aboutsensation. If sensed, it is repositioned. Third, currentflow is initiated and brought to 2 MA, slowly. Depres-sion of the current increase or decrease button resultsin gradual current change. Some patients may sense thetip at this time, allowing for a decrease to zero currentand repositioning. A low milliampere current flow al-lows for case in probe tip tissue penetration. A needle-sharp tip is not required if this technique is used.Fourth, after tip insertion into the hemorrhoid base,additional current flow is applied slowly. Increasing 2to 4 mA every 15-30 s is generally well tolerated. Apatient may be intolerant of moderate milliamperevalues during the first several minutes of therapy, afterwhich a very gradual increase in current may be appliedwithout discomfort. This may relate to local effects ofdirect current on the rectal autonomic innervation dur-ing the first portion of the treatment session with re-sultant desensitization.

The precise mechanism of action of direct current tobring about resolution of hemorrhoid disease is notknown. Thrombosis of the hemorrhoid vascular net-work and associated vasa vasorum with eventual tissueresorption or slough is the postulated end result (7).When applied to hemorrhoid tissue, the negative poleof direct current could theoretically result in vascularthrombosis directly or. in events, eventually precipitat-ing thrombosis by several mechanisms. /) Generationof heat at the probe tip. Using a mean body resistanceof 1000 ohms, 10 mA current flow results in an appliedvoltage of 10 V. Voltage times amperes equals watts,one watt of current applied for I h is equivalent to 860calories or the ability to raise 860 ml of water TC in 1h. Applied to the treatment of hemorrhoid disease. 10mA is equal to 0.1 W applied. If applied for 10 min, amaximum of 14.3^ could result—probably an insuf-ficient mechanism to bring about this therapeutic effect.In support of the lack of participation of direct current-generated heat are preliminary data using a thermistertechnique to measure tissue temperature between thedual probe tips. There was no significant temperaturechange when 10 mA were applied for 5 min to themesenteric vein of the dog (Dennis M. Jensen. M.D.,personal communication). 2) Direct trauma to thehemorrhoid vascular network by the probe tip. The sig-nificant difference of milliampere-minute product fortreatment of different hemorrhoid grades demonstratesthat trauma by the probe tip alone is insufficient tobring about disease resolution. 3) Vascular spasm ofhemorrhoid network or associated vasa vasorum. It is

Vol. 84. No. 5. 1989

Biochemical Response

H,0

Grounding Pad Electrode

Fi(i. 2. The mechanism by which the negative electrode of directcurrent applied lo hemorrhoid vasculature results in a thrombogenicand desiccating chemical rcaclion.

well established that direct current applied to a solutionof salt (NaCl). as present in a tissue environment, resultsin the hydroxyl molecule of water binding to sodium.This may result in membrane water shifts with resultantintracellular constituent concentration. An increase incytosoiic CA '̂̂ concentration may initiate a CA*^-dependent phosphorylation reaction with resultantsmooth muscle contraction (8). 4) A chemical reaction(Fig. 3). Direct current results in the disassociation ofwater to OH" and H"̂ which occurs at 1.2 V. Dependingon the concentration of NaCl. NaCl will disassociatewith the formation of NaOH at the negative electrode.Hydrogen gas is a resultant by-product of the formationof NaOH and is released. Tissue destruction by NaOHmight then result in the release of thrombogenic sub-stances. This chemical reaction results in tissue volumeloss. This mechanism may explain the tissue shrinkagewe observed and has been described with direct currentapplication to hemorrhoid disease (6). Additionally, ifthe true positive electrode for the above reactions iswithin the hemorrhoid vascular network because oftissue resistance factors to current flow, rather than theapplied grounding pad, free chlorine gas from Cl" oxi-dation may contribute directly (thrombogenesis) or in-directly (tissue destruction) to the hemorrhoid clottingprocess. Finally, other ions than Na* and CI" may beoxidized or reduced by direct current application tohemorrhoid disease and contribute to the results pre-sented.

Direct current offsets many concerns raised withother hemorrhoid therapies. It is successful on all gradesof internal and mixed hemorrhoid disease. Properiyapplied, the procedure is painless. No bowel prepara-tion, anesthetic, or medication is required. Patients areable to resume normal activities immediately after ther-apy. No major and only rare minor complicationswithout sequelae dictate the safety of the procedure.Apparent sustained symptom resolution can be ex-pected, and patient acceptance is good. However, morethan one treatment is required in about one-fourth of

May 1989 DC ELECTROTHERAPY OF INTERNAL HEMORRHOIDS 487

hemorrhoids, while the average treatment of hemor-rhoids is approximately 11 min. Hence, successful treat-ment overall requires a dedication to the approach.Finally, the asymptomatic follow-up period is relativelylimited to date, and continued study is required.

Reprint requests: Daniel A. Norman, M.D.. F.A.C.P.. P.O. Box18.100. 1090 Second Street, Soulii Lake Tahoe. CA 95706.

REFERENCES1. Banov L Jr. Knoepp LF Jr. Erdman LH, et al. Management of

hemorrhoid disease. J SC Med Assn 1985:81:398-401.

2. Federal Register 1980:45:35584.3. O'Connor JJ. Infrared coagulation of hemorrhoids. Pract Gas-

troenterol 1986:10:8-14.4. Schrock TR. Diseases of the anoreetum. In: Sleisenger MH,

Fordtran JS. eds. Gastrointestinal disease. 3rd ed. Philadelphia:WB Saunders, 1983:1280-93.

5. Guthrie JF. The current management of hemorrhoids. PractGastroenterol 1987:11:56-66.

6. Keesey WE. Obliteration of hemorrhoids with negative galva-nism. Arch Phys Ther 1934:15:533-40.

7. Webb JC. Treatment of hemorrhoids by electrolysis. Br Med J1921:1:457.

8. Katz AM, Hager WD. Messineo FC. et a!. Cellular actions andpharmacology of the calcium channel-blocking drugs. Am J Med1985:79:2-10.