External hemorrhoids are folds of dry, epithelialized (not moist, mucosa-covered) anal skin. It is quite normal to have external hemorrhoidal or anal skin folds, which are necessary to allow the anal canal to expand during bowel movements. The presence of apparently large external hemorrhoidal folds or tags is not an indication of disease or underlying abnormality.
Enlarged external hemorrhoids are present in many women after pregnancy and do not recede.
Although many symptoms in the anal region are attributed to "external hemorrhoids", in most instances there is another cause for the symptom and the external anal (or hemorrhoidal) skin is only the site where discomfort is felt, not the cause. (see separate topics: Anal fissure, Hemorrhoids, Pruritis Ani, Fistula in Ano)
External hemorrhoids rarely require surgical treatment, even if thrombosed. Small external hemorrhoids, if removed surgically, recur, and the operation is very painful, moreso than one would imagine.
Thrombosed hemorrhoids occur when small hemorrhoidal veins develop thrombi, causing swelling and pain. Although the pain can be severe at first, the thrombi resolve on their own without treatment over 2-3 weeks. I&D to remove the thrombi does not always hasten the healing or reduce the pain, once the local anesthesia has worn off.
The only indication for surgical removal of an external hemorrhoid is marked enlargement, e.g., a pedunculated tag 2-3 cm in size.
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