Hemorrhoids are a normal part of the human anorectal anatomy. They do not constitute a disease unless they become symptomatic. The prevalence of symptomatic hemorrhoids in the United States is reported to be 4.4%, affecting men and women equally. Hemorrhoid disease accounts for 3.2 million ambulatory care visits, 306,000 hospitalizations and the issue of over 2 million prescriptions a year. Hemorrhoids, when symptomatic, can be treated successfully. Treatment can be divided into four different steps:
Step 1: Dietary and Lifestyle Modification
Constipation is one of the most common causes of symptomatic hemorrhoid disease. Dietary management with increased fiber and water intake is the primary noninvasive mean to treat constipation.
– Psyllium is the principal fiber supplement used in concert with water to add moisture to the stool, ameliorating constipation.
-Other alternative medications include witch hazel, horse chestnut, ginger root, butchers broom, rutin, hesperidin and diosmin – all mainly used in homeopathic medicine.
Step 2: Topical Agents
Most of the creams, ointments and suppositories prescribed for the treatment of symptomatic hemorrhoids contain corticosteroids. They are good for the short-term treatment of the hemorrhoid flare, but its chronic use is discouraged do to the possibility of permanent damage to the perianal skin. They could also promote opportunistic infections such as fungal dermatitis. Some creams are mixed with local anesthetics such as lidocaine and pramoxine, which could give short-term relief. Other alternative medications that are used locally are astringents such as Witch Hazel (Hammamelisvirginiana), Aloe Vera and phenylephrine.
Step 3: In-Office Procedures
The goal of in-office procedures is to ablate the vessels involved and fix the sliding hemorrhoidal tissue back onto the muscle wall of the anal canal with minimal pain. These procedures include:
Sclerotherapy: indicated for grade 1 and 2 internal hemorrhoids. It involves a submucosal injection of a sclerosant at the apex of the hemorrhoid and usually causes thrombosis of the vessels with shrinkage and fixation.
Rubber Band Ligation: the most commonly used in-office procedure, indicated for internal hemorrhoids grades 1, 2 and 3. Ligators deploy a rubber band around a hemorrhoid pedicle. The procedure is usually painless and takes only a few minutes to perform. The ligated tissue usually necroses and sloughs in 3-4 days, causing elimination of the redundant tissue and fixation.
Infrared Coagulation (IRC): produces an infrared light which penetrates the tissue and converts to heat, promoting coagulation of the vessels and fixation. It is usually indicated for small bleeding internal hemorrhoids, grade 1.
Electrocoagulation and Bipolar Coagulation: indicated for small bleeding internal hemorrhoids, relies on coagulation and fixation as other techniques. It is somehow less effective and more painful than RBL and IRC.
Direct-Current Electrotherapy (Ultroid): is similarly applied through a probe placed via an anoscope into the mucosa at the apex of the hemorrhoid. It is a lengthy procedure and reapplications to the same site are sometimes required.
Thrombectomy: usually indicated for the therapy of small thrombosed external hemorrhoids. The procedure usually does not excise the involved hemorrhoid complex, but rather evacuates the blood clot beneath the anal skin, relieving the tension and pain immediately.
Step 4: Surgical treatment
Several options and techniques are available for the surgical treatment of symptomatic hemorrhoids. They include:
Doppler Guided Hemorrhoidal Artery Ligation: using a Doppler transducer, the hemorrhoidal arteries are identified and ligated. It causes less pain than a traditional surgical hemorrhoidectomy, but sometimes, the large prolapse of grade 4 internal hemorrhoids or the prolapsing of large external hemorrhoids are difficult to address.
Excisional Hemorrhoidectomy: several techniques exist to excise the hemorrhoid tissue, including: the closed or Ferguson, the open or Milligan-Morgan, the Nd-YAG laser, and the use of energy instruments such as the Harmonic Scalpel and Ligasure. Postoperative pain and prolonged healing time are some main disadvantage. Long-term results are usually excellent.
Stapled Hemorrhoidectomy: also known as PPH (procedure for prolapsed hemorrhoids), thought to decrease the amount of postoperative pain. A portion of the rectal mucosa and submucosa close to the apex of the hemorrhoid pedicle is excised and stapled again. The hemorrhoids are re-suspended and brought back into the anal canal. A major drawback of this technique is that the procedure does not treat the large external hemorrhoids and associated tags sometimes present. The use of PPH is limited to patients with large grade 3 and 4 internal hemorrhoids.