1. Apakah hemorrhoid externa berasal dari squamous sel?2. Hubungan anatomi terhadap faktor risiko terjadi hemorrhoid?Hemorrhoids are not varicosities; they are clusters of vascular tissue (eg, arterioles, venules, arteriolar-venular connections), smooth muscle (eg, Treitz muscle), and connective tissue lined by the normal epithelium of the anal canal. Hemorrhoids are present in utero and persist through normal adult life. Evidence indicates that hemorrhoidal bleeding is arterial and not venous. This evidence is supported by the bright red color and arterial pH of the blood.Hemorrhoids are classified by their anatomic origin within the anal canal and by their position relative to the dentate line; thus, they are categorized into internal and external hemorrhoids.External hemorrhoids develop from ectoderm and are covered by squamous epithelium, whereas internal hemorrhoids are derived from embryonic endoderm and lined with the columnar epithelium of anal mucosa. Similarly, external hemorrhoids are innervated by cutaneous nerves that supply the perianal area. These nerves include the pudendal nerve and the sacral plexus. Internal hemorrhoids are not supplied by somatic sensory nerves and therefore cannot cause pain. At the level of the dentate line, internal hemorrhoids are anchored to the underlying muscle by the mucosal suspensory ligament. External hemorrhoidal veins are found circumferentially under the anoderm; they can cause trouble anywhere around the circumference of the anus.

3. Mengapa terjadi retensio urin pada post hemorrhoidectomy? Urinary retentionUrinary retention can occur in up to 15% of patients posthemorrhoidectomy. Many factors are thought to contribute to urinary retention following hemorrhoidectomy, with pain being a major contributor. Perioperative restriction of fluid intake has been shown to reduce the need for catheterization. In general, most patients have no further issues after 1 catheterization. Men with enlarged prostates may require an indwelling Foley catheter for up to 72 hours.Urinary retention, which is the most common complication following hemorrhoidectomy, occurs is as many as 20% of patients. Factors often held responsible include the following : Spinal anesthesia Rectal pain and spasm High ligation of the hemorrhoidal pedicle Rough handling of tissue Heavy suture material Numerous sutures Fluid overload Rectal packing Tight, bulky dressings Anticholinergics NarcoticsGenerally, the incidence of urinary retention is not felt to be altered by the prophylacticadministration of Urecholic (bethanechol chloride). Prophylactic alfa adrenergic blockade has failed to prevent this complication, as has the administration of an anxiolytic agent.

Rubber Band Ligation. Persistent bleeding from first-, second-, and selected third-degree hemorrhoids may be treated by rubber band ligation.Mucosa located 1 to 2 cm proximal to the dentate line is grasped and pulled into a rubber band applier. After firing the ligator, the rubber band strangulates the underlying tissue, causing scarring and preventing further bleeding or prolapse (Fig. 29-31). In general, only one or two quadrants are banded per visit. Severe pain will occur if the rubber band is placed at or distal to the dentate line where sensory nerves are located. Other complications of rubber band ligation include urinary retention, infection, and bleeding. Urinary retention occurs in approximately 1% of patients and is more likely if the ligation has inadvertently included a portion of the internal sphincter. Necrotizing infection is an uncommon, but life-threatening complication. Severe pain, fever, and urinary retention are early signs of infection and should prompt immediate evaluation of the patient usually with an exam under anesthesia. Treatment includes dbridement of necrotic tissue, drainage of associated abscesses, and broad-spectrum antibiotics. Bleeding may occur approximately 7 to 10 days after rubber band ligation, at the time when the ligated pedicle necroses and sloughs. Bleeding is usually self-limited, but persistent hemorrhage may require exam under anesthesia and suture ligation of the pedicle.