• External hemorrhoid - distal to dentate line
• Internal hemorrhoid - proximal to dentate line
• Grade I - do not prolapse past dentate line
• Grade II - prolapse out of anal canal with defecation or straining, but reduce spontaneously
• Grade III - prolapse out of anal canal with defecation or straining, and require manual reduction
• Grade IV - irreducible, may strangulate

Conservative management

• Fiber, water
• Avoid constipation
• Don't linger on toilet

Indications for operation

• Symptomatic hemorrhoids refractory to conservative measures
• Thrombosed external hemorrhoid within 1st 72 hrs - after this time, pain lessens and surgery is not needed

Operative

• Low risk of infxn; don't need pre-op abx
• Hemorrhoidectomy vs. hemorrhoidal artery ligation
• Op note

Post-op care - discharge from PACU

• Sitz baths
• Stool softeners
• Encourage acetaminophen over opioids (avoid constipation)