What is the management of 4th degree hemorrhoids?

Management of 4th Degree Hemorrhoids

Surgical hemorrhoidectomy is the most effective treatment for 4th degree hemorrhoids and should be recommended as the primary treatment option for these patients. 1

Diagnosis and Assessment

When evaluating a patient with suspected 4th degree hemorrhoids:

• Perform a complete physical examination including digital rectal examination to confirm diagnosis 1
• Conduct anoscopy to visualize the hemorrhoids when feasible and well tolerated 1
• Consider colonoscopy if there are concerns for inflammatory bowel disease or cancer based on patient history or physical examination findings 1

Fourth-degree hemorrhoids are defined as internal hemorrhoids that have prolapsed and cannot be reduced manually 1. This represents the most advanced stage of hemorrhoidal disease.

Treatment Algorithm

First-line Management

While non-operative management is recommended as first-line therapy for complicated hemorrhoids in general 1, for 4th degree hemorrhoids specifically:

• Surgical hemorrhoidectomy is the treatment of choice due to the advanced nature of the disease 1
• Indications for hemorrhoidectomy include:
  • Symptomatic fourth-degree hemorrhoids
  • Mixed internal and external hemorrhoids
  • Failure of non-operative therapy
  • Patient preference after discussion of options 1

Surgical Options

Several surgical techniques are available:

1. Conventional hemorrhoidectomy (open or closed):

   • Most effective treatment with lowest recurrence rates 1
   • Associated with more pain and longer recovery time 1
   • Can be performed with either open (Milligan-Morgan) or closed (Ferguson) techniques 1

2. Stapled hemorrhoidopexy:

   • Associated with significantly less pain than conventional hemorrhoidectomy 1
   • Results appear comparable to conventional hemorrhoidectomy in short-term follow-up 1
   • However, may have limitations in treating 4th degree hemorrhoids 2
   • Higher recurrence rates compared to conventional hemorrhoidectomy 3

3. Advanced energy devices:

   • LigaSure and harmonic scalpel techniques show lower complication rates 3
   • May result in less postoperative pain 3

Perioperative Considerations

• Administer prophylactic antibiotics before surgery 2
• Perform the procedure under general anesthesia with the patient in lithotomy position 2
• Administer appropriate pain management postoperatively 1
• Most patients can be discharged within 1-2 days after surgery 2

Special Considerations

• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids: Should undergo either hemorrhoidectomy or excision of the external component with rubber band ligation of the internal hemorrhoids 1

• Avoid manual dilatation of the anus during surgery due to risk of sphincter injury and incontinence 1

• Laser hemorrhoidectomy has no advantage over conventional techniques and is more costly 1

Postoperative Care

• Sitz baths and analgesics for pain management
• Stool softeners to prevent constipation
• Follow-up evaluation at 1-2 weeks after surgery
• Most patients can return to normal activities within 2-3 weeks 2

Potential Complications

• Pain (most common)
• Bleeding
• Urinary retention (occurs in approximately 5-6% of patients) 2
• Fecal urgency (temporary in most cases) 2
• Recurrence (approximately 6-7% for 4th degree hemorrhoids) 2

While non-operative approaches like rubber band ligation, sclerotherapy, and infrared coagulation are effective for lower-grade hemorrhoids, they are generally inadequate for the management of 4th degree hemorrhoids, which require definitive surgical intervention for optimal outcomes in terms of morbidity, mortality, and quality of life.