Hemorrhoids Treatment

• 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

• 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

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)

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