hemorrhoids
HEMORRHOIDS
Hemorrhoids are swollen and inflamed vascular structures or veins around the anus or in the lower rectum.
External hemorrhoids are located closer to the anal verge and are covered with squamous epithelium. It produces symptoms only when thrombosed or when they give rise to large skin tags which make hygiene difficult. Common symptoms are anal pain of acute onset and a palpable lump in the perianal area.
Internal hemorrhoids originate above the dentate line and are covered with rectal or transitional mucosa. It does not cause cutaneous pain. Prolapse of internal hemorrhoids may cause bleeding, mucus discharge, fecal soiling and anal pruritus.

Principles of Therapy

  • Treatment options for painful thrombosed external hemorrhoids include observation or excision
  • Excision within the 1st 48-72 hours after symptom onset in the office or, if necessary, in the operating room typically results in a more rapid relief of symptoms
  • If the pain is not too severe, is resolving, and onset is >72 hours, the patient may be treated expectantly since pain usually resolves in 7-10 days

Ablative Office Procedures

Principles of Therapy:

  • Patients with intractable grade I, II or III hemorrhoids are the usual candidates for office-based (outpatient) procedures
  • The need for treatment of hemorrhoids is based on the patient’s symptoms and not on the appearance of the hemorrhoids
  • Ablation of the mucosal portion of the hemorrhoidal complex does not require anesthesia

Goals of Therapy:

  •  Decrease vascularity, decrease hemorrhoidal volume and increase fixation of the fibrovascular cushion to the rectal wall
  •  Choice of procedure depends partly on the physician’s experience and preference

Pharmacotherapy

  • Several pharmacological preparations for hemorrhoidal relief are available
  • More studies are needed to demonstrate their definite role in the treatment of hemorrhoids

Analgesics

  • Topical analgesics may be used to relieve local pain and pruritus
    • Includes Lidocaine, Cinchocaine
  • Oral analgesics (eg Paracetamol) may be used to relieve pain caused by thrombus

Corticosteroids

  • Topical corticosteroids can reduce perianal inflammation due to poor hygiene, mucus discharge or fecal seepage
  • Avoid prolonged use of potent corticosteroids

Bioflavonoids

  • Oral, micronized, purified, flavonoid fraction derived from citrus fruits have been studied
  • Control rectal bleeding, improve symptoms
  • Actions: Increase venous tone, lymphatic drainage and capillary resistance; normalize capillary permeability

Other Agents

  • Stool softeners have a limited role in hemorrhoid therapy
  • Suppositories may help in lubrication during defecation, thus avoiding straining
  • Various laxatives and purgatives for hemorrhoids are available. Please see the latest MIMS for specific formulations and prescribing information

Non-Pharmacological Therapy

Toilet Habit Retraining

  • Consists mainly of reminding patients to avoid prolonged sitting or straining when using the toilet
  • Reading when using the toilet should be avoided

Warm Baths and Ice

  • Warm water baths relieve perianal pain by relaxing the anal sphincter mechanism and spasm
  • Ice may lessen the pain of acute thrombosis

Hygiene

  • Patients may be advised to wipe anal area gently after defecation with moist tissue
  • Discourage excessive scrubbing during shower/bath

Other

  • Avoidance of medications that promote bleeding eg nonsteroidal anti-inflammatory drugs (NSAIDs)

Ablative Office Procedures

Rubber Band Ligation

  • Most commonly used for grade I, II or III hemorrhoids
  • Usually the most effective option
  • Redundant mucosa, connective tissue and hemorrhoidal complex blood vessels are tightly encircled well proximal to the dentate line
  • Scar that forms fixes connective tissue to the rectal wall and resolves the prolapse
  • Single or multiple banding may be done per session
    • Up to 3 hemorrhoids can be banded in one session
  • Limitation of the procedure: Does not address the external hemorrhoidal component
  • Most common complication is minor pain
  • Recurrent symptoms may be relieved by repeat ligations
  • Avoid in patients with bleeding diathesis or those receiving antiplatelet or anticoagulant agents

Sclerotherapy

  • Used for grade I or II hemorrhoids
  • A sclerosing agent is injected into the apex of the hemorrhoid
  • Vessel thrombosis, with sclerosis of connective tissue and fixation of overlying mucosa, results
  • Minimally invasive nature is an advantage
  • Complications include pain, bleeding with injection, impotence, urinary retention and abscess

Bipolar Diathermy or Cautery

  • May be used for grade I, II or III hemorrhoids
  • 1-second pulses of 20 W are applied until underlying tissue coagulates resulting in fibrosis and fixation of tissue
  • Usually requires multiple applications to the same site
  • About a fifth of patients still require excisional hemorrhoidectomy
  • Complications include pain, bleeding, fissure or spasm of the internal sphincter

Direct Current Electrotherapy

  • May be used for grade I, II or III hemorrhoids
  • Involves prolonged application of 110 V direct current to the base of the hemorrhoidal complex
  • Requires multiple applications to the same site in about a third of patients
  • Disadvantages are extended treatment time and limited control of prolapse in more severe disease

Infrared Coagulation

  • May be used for grades I or II hemorrhoids
  • Infrared waves are applied directly to the base of hemorrhoidal tissue, resulting in protein necrosis
  • Recurrence is common in hemorrhoids with marked prolapse

Cryotherapy

  • Employs cold coagulation
  • Rarely used because of significant adverse effects
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