1. Bleeding per rectum(from the anus)
2. Mucosal discharge(thick watery)
3. Rectal fullness when piles are large
4. Severe pain due to infection or thrombosis or necrosis

The diagnosis is based on history, physical examination, and endoscopy.

• Grade l: Internal hemorrhoid bulges into the anal canal during bowel movements(passing motions).
• Grade ll: Internal hemorrhoid bulges from the anus while passing stools, then goes back inside by itself.
• Grade lll: Internal hemorrhoid bulges from the anus during bowel movements and must be pushed back in with a finger(by patient/surgeon).
• Grade lV: Internal hemorrhoid protrudes from the anus all the time which can’t be reduced back into the anal canal

A. Medical management

1. High fiber diet(fruits, vegetables, etc)
2. Adequate hydration(proper intake of water)
3. Stool softener (in case of constipation)
4. To decrease the time spent on the toilet

B. surgical Management

Usual treatment options :
1. Change of diet and lifestyle (Grade I)
2. Lotions, medicaments, ointments (Grade I)
3. Rubberband, sclerotherapy, infrared coagulation (Grade I + II)
4. Closed surgery: Stapler Hemorrhoidopexy (Grade III)
5. Open surgery: Milligan-Morgan, Parks (Grade III + IV)
6. Hemorrhoid Laser Procedure(all grades).

1. Couple of days to a week in the hospital
2. Pain for 7-10 days
3. Postoperative bleeding
4. Infections
5. Abcess
6. Problems with sitting
7. Open wounds need 4-6 weeks to heel
8. Necessity of taking baths

• Minimally invasive laser therapy of hemorrhoids
• Controlled hemorrhoidal shrinkage
• Very good hemostasis
• Maximized preservation of continence
• Small wound sizesLaser HemorrhoidoPexy (LHP)
  Also known as LaserHemorrhoidoPlasty
  This approach is used for the treatment of hemorrhoids under appropriate anesthesia. The fiber of the laser is inserted centrally into the hemorrhoidal node and energy is delivered. By this technique, hemorrhoids can be treated according to their size without causing any damage to the anoderm or mucosa.

• If surgery is indicated, this therapy will provide you with an improved patient outcome especially regarding pain and recovery compared to conventional surgical proceeding for 2nd, 3rd, and 4th-degree hemorrhoids.
• Under proper local or general anesthesia, the controlled laser energy delivery obliterates the hemorrhoids from the inside and preserves the mucosa and sphincter structures to an extremely high degree(Tissue reduction in the hemorrhoids).
• The controlled emission of laser energy, which is applied submucosally, causes
  the hemorrhoidal mass to shrink.
• In addition, fibrotic reconstruction generates new connective tissue, which ensures that the mucosa adheres to the underlying
  tissue.
• This also prevents the occurrence or recurrence of prolapse. Laser hemorrhoidopexy is not associated with any risk of stenosis. Healing/result is excellent because, unlike conventional surgeries, there are no incisions/cut or stitches.
• Access to the hemorrhoid is achieved by entering through a small perianal port. By this approach, no wounds are generated in the area of the anoderm or mucosa. As a result, the patient experiences less post-operative pain and can return to normal activities within a shorter space of time.
  1. No incisions
  2. No excisions
  3. No open woundsThree treatment principles with laser:
  1.  Reduction of the hemorrhoidal tissue, not total destruction/excision
  2. Reconstruction of the natural anatomy
  3. Nontouch of the anoderm

1. Diode Laser 980/1470nm
2. Laser Fiber: Delivery of energy in a conical shape

Characteristics of lasers fibers
1. Standard is bare fiber
2. Working mechanism: High temperatures on the fiber tip lead to a hot needle effect.
3. Temperature gradient to surrounding tissue structures.

• Painless procedure
• Outpatient or short hospital stay (overnight)
• Short downtimes
• No stenosis
• No incontinence
• No mucosa damaging
• No foreign body insertion (no clamp complications)
• Less complications
• Safe procedure
• Smaller wound
• Low complication rate
• Early Return to work
• High patient satisfaction

Patients and Methods
Between November 2010 and November 2016, 497 patients (age 55 ± 14 years) were submitted to laser haemorrhoidoplasty with a 1470 nm diode laser in the center for minimally invasive proctology in Siegen District Hospital. All operated patients were included in the study. Perioperative clinical and technical data up to 6 weeks and follow-up data up to 6 months were analyzed prospectively.

Results
The mean duration of operation was 14 min (± 5.2). A mean of 2.7 knots of 2.7 size was treated per patient. The mean postoperative pain was 2.5/10 (VAS). Long-term symptom relevance was 86%, and patient satisfaction 91%. Complications occurred in 49 patients (9.9%): bleeding 1.8%, infection 1%, urine retention 1.8%, oedema/thrombosis/prolapse 6.6%. 8.8% of patients suffered a relapse within 6 months. There were significant differences in pain on the day of the operation, and the parameters mucopexia, 3 treated segments, and energy level > 500 J (p < 0.05). Complications were more common when mucopexia was performed, with 3 treated knots and energy consumed per patient > 500 J. The only significant difference was for energy level > 500 J (p < 0.05).

Conclusion
LHP is a safe, low pain and minimally invasive surgical procedure with long-term good patient acceptance and satisfaction and is suited for routine work. The energy applied should be reduced to a minimum. Complication rates are largely comparable with those of other minimally invasive conventional methods. Additional prospective studies must be performed, particularly in comparison to the Parks method, which gives similar functional results. With circular confluent findings, LHP cannot replace stapler hemorrhoidopexia.