What is the recommended treatment approach for external hemorrhoidectomy?

From the Guidelines

The recommended treatment approach for external hemorrhoidectomy is surgical excision, with the decision between non-operative management and early surgical excision based on local expertise and patient preference, as suggested by the most recent guidelines 1.

Key Considerations

• The procedure itself requires surgical removal of the external hemorrhoidal tissue under appropriate anesthesia, typically local with sedation or regional anesthesia.
• Postoperatively, pain management is essential and should include scheduled acetaminophen and NSAIDs for the first 3-5 days, with opioid medications for more severe pain.
• Stool softeners should be started immediately after surgery to prevent constipation, and sitz baths can help reduce pain and keep the area clean.
• Patients should maintain adequate hydration and consume a high-fiber diet to facilitate comfortable bowel movements, and activity should be gradually increased, avoiding heavy lifting for 2 weeks.

Evidence-Based Recommendations

• A study by Greenspoon et al. 1 found that surgical treatment resulted in a significantly shorter time to symptom resolution and reduced incidence of recurrence compared to conservative management.
• Another study by Jongen et al. 1 concluded that outpatient excision under local anesthesia can be safely performed with a low recurrence and complication rate.
• The guidelines suggest against the use of incision and drainage of the thrombus due to higher incidence of bleeding and relapse of symptoms 1.
• The American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids also supports surgical hemorrhoidectomy as a treatment option for external hemorrhoids, with a focus on minimizing postoperative pain and complications 1.

From the Research

External Hemorrhoidectomy

The recommended treatment approach for external hemorrhoidectomy is primarily surgical, with the goal of relieving symptoms such as pain and discomfort.

• Surgical Options:
  • Excision of thrombosed external hemorrhoids is a common procedure for external hemorrhoidectomy, especially when performed within the first two to three days of symptoms 2.
  • Incision and drainage may be considered as an initial treatment for thrombosed external hemorrhoids, followed by excision if necessary 3.
• Postoperative Care:
  • Patients may experience complications such as bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, or incontinence after standard hemorrhoidectomy 3.
  • Proper wound care and follow-up are essential to minimize the risk of complications.
• Alternative Treatments:
  • Conservative management, including dietary modifications, stool softeners, and topical treatments, may be considered for patients with mild symptoms or as an adjunct to surgical treatment 4, 5.
  • Rubber band ligation is generally recommended for internal hemorrhoids, but may not be suitable for external hemorrhoids 4, 2, 5, 6.
• Considerations:
  • The choice of treatment should be individualized based on the patient's symptoms, medical history, and preferences 4.
  • Patients with underlying conditions, such as anal stenosis or incontinence, may require special consideration and alternative treatment approaches 3.