Chapter 13: Hemorrhoids

The Burden of Digestive Diseases in the United States

James E. Everhart, M.D., M.P.H.

Hemorrhoids are classified as diseases of the circulatory system by ICD-9 and ICD-10 (Appendix 1), but are much more often diagnosed and treated by digestive disease specialists than by those with a primary interest in the circulatory system. Therefore, burden data for hemorrhoids are presented in this report. Hemorrhoids are subclassified by anatomical location (internal or external) and whether they are complicated with bleeding, prolapse, strangulation, or ulceration. Hemorrhoids are common, and their treatment is primarily in the ambulatory care setting. In 2004, there were an estimated 2 million ambulatory care visits with hemorrhoids as first-listed diagnosis and 3.2 million visits at which hemorrhoids were an all-listed diagnoses (Table 1), which made hemorrhoids the fourth or fifth leading outpatient digestive system diagnosis (after GERD, abdominal wall hernia, and functional disorders, and essentially tied with diverticular disease). Visit rates were highest among persons age 65 years and older and among whites. Age-adjusted rates were similar for males and for females. Most hospitalizations for hemorrhoids are for surgery, which is performed most often as same-day surgery; thus, the number of hospitalizations for hemorrhoids was small relative to the number of ambulatory care visits (Table 1). As opposed to rates of ambulatory care visits, age-adjusted hospitalization rates were higher for blacks than whites. Hemorrhoids were most often listed as a secondary diagnosis (87 percent).

Age-adjusted ambulatory care visits for hemorrhoids declined slightly between the periods of 1992–1993 and 2003–2005 (Figure 1). The rate of visits in this latter period was about 20 percent lower than in the early 1980s, continuing a trend in declining outpatient visits that began in the 1960s.4 Overnight hospitalizations with hemorrhoids listed as a diagnosis declined by about 60 percent from 1981 to 1994, and were relatively stable for the following 10 years. As a first-listed hospital diagnosis, hemorrhoids declined much more: from about 70 per 100,000 in 1979 to 13 per 100,000 in 2004.5

Death from hemorrhoids has always been exceedingly rare (Table 2 and Figure 2). There was a substantial decline from 1980 through 2004 in hemorrhoids noted as a diagnosis on death certificates.

Nearly 2 million prescriptions for hemorrhoids were filled at retail pharmacies in 2004, according to Verispan (Appendix 2), with topical medications such as pramoxine (pramocaine) and hydrocortisone and stool softeners such as psyllium most often prescribed (Table 3). Most persons with hemorrhoids do not seek medical care and are self-treated using nonprescription medications similar to those listed in Table 3; thus the totals in this table were a small portion of the number and cost of medications used to treat hemorrhoids.6

References

Table 1. Hemorrhoids: Number and Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With First-Listed and All-Listed Diagnoses by Age, Race, and Sex in the United States, 2004

Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (3-year average, 2003–2005), and Healthcare Cost and Utilization Project Nationwide Inpatient Sample (HCUP NIS)

Demographic Characteristics Ambulatory Care Visits First-Listed Diagnosis Number in Thousands Ambulatory Care Visits First-Listed Diagnosis Rate per 100,000 Ambulatory Care Visits All-Listed Diagnosis Number in Thousands Ambulatory Care Visits All-Listed Diagnosis Rate per 100,000 Hospital Discharges First-Listed Diagnosis Number in Thousands Hospital Discharges First-Listed Diagnosis Rate per 100,000 Hospital Discharges All-Listed Diagnosis Number in Thousands Hospital Discharges All-Listed Diagnosis Rate per 100,000
AGE (Years)
Under 15
1 1
AGE (Years)
15–44
716 569 1,131 899 8 7 57 46
AGE (Years)
45–64
915 1,294 1,331 1,883 13 19 96 136
AGE (Years)
65+
387 1,065 790 2,174 16 45 152 418
Race
White
1,819 724 2,915 1,161 29 11 245 96
Race
Black
145 421 234 656 6 19 45 150
Sex
Female
944 621 1,745 1,132 19 12 179 110
Sex
Male
1,092 751 1,531 1,061 19 14 127 95
Total 2,036 693 3,275 1,115 38 13 306 104

Figure 1. Hemorrhoids: Age-Adjusted Rates of Ambulatory Care Visits and Hospital Discharges With All–Listed Diagnoses in the United States, 1979–2004

The rate of ambulatory care visits over time (age-adjusted to the 2000 U.S. population) is shown by 3-year periods (except for the first period which is 2 years), between 1992 and 2005 (beginning with 1992–1993 and ending with 2003–2005). Ambulatory care visits per 100,000 declined slightly from 1,122 in 1992–1993 to 1,093 in 2003–2005. Hospitalizations per 100,000 declined from 139 in 1979 to 52.3 in 1994, and were relatively stable through 2004 when the rate was 59.9.
Source: National Ambulatory Medical Care Survey (NAMCS) and National Hospital Ambulatory Medical Care Survey (NHAMCS) (averages 1992–1993, 1994–1996, 1997–1999, 2000–2002, 2003–2005), and National Hospital Discharge Survey (NHDS)

Table 2. Hemorrhoids: Number and Age-Adjusted Rates of Deaths and Years of Potential Life Lost (to Age 75) by Age, Race, and Sex in the United States, 2004

Source: Vital Statistics of the United States

Demographic Characteristics Underlying Cause Number of Deaths Underlying Cause Rate per 100,000 Underlying Cause Years of Potential Life Lost in Thousands Underlying or Other Cause Number of Deaths Underlying or Other Cause Rate per 100,000
AGE (Years)
Under 15
AGE (Years)
15–44
2 0.0 0.1 5 0.0
AGE (Years)
45–64
8 0.0 0.2 22 0.0
AGE (Years)
65+
4 0.0 0.0 30 0.1
Race
White
9 0.0 0.1 42 0.0
Race
Black
2 0.0 0.0 9 0.0
Sex
Female
3 0.0 0.0 21 0.0
Sex
Male
11 0.0 0.2 36 0.0
Total 14 0.0 0.2 57 0.0

Figure 2. Hemorrhoids: Age-Adjusted Rates of Death in the United States, 1979–2004

Deaths declined substantially from 1980 through 2004. Underlying-cause mortality per 100,000 decreased from 0.01 in 1979 to less than 0.01 in 2004. All-cause mortality per 100,000 decreased from 0.07 in 1979 to 0.02 in 2004.
Source: Vital Statistics of the United States

Table 3. Hemorrhoids: Costliest Prescriptions

Source: Verispan

DRUG Prescription (#) Prescription Retail Cost Cost
Pramoxine/Hydrocortisone 336,508 16.9% $19,424,146 45.1%
Hydrocortisone 989,521 49.8 14,852,947 34.5
Hydrocortisone/Lidocaine 98,928 5.0 6,288,920 14.6
Docusate 511,791 25.7 1,672,743 3.9
Hydrocodone/Acetaminophen 15,223 0.8 437,436 1.0
Oxycodone/Acetaminophen 2,550 0.1 116,818 0.3
Psyllium 7,715 0.4 80,312 0.2
Polycarbophil 14,496 0.7 43,635 0.1
Bismuth subgallate/Zinc oxide/Balsam 4,099 0.2 42,819 0.1
Ibuprofen/Hydrocodone 858 0.0 25,637 0.1
Other 4,296 0.2 39,848 0.0
Total 1,985,985 100.0% $43,025,261 100.0%
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