What is the recommended treatment for a fourth degree hemorrhoid?

Treatment for Fourth Degree Hemorrhoids

Surgical hemorrhoidectomy is the recommended treatment for fourth-degree hemorrhoids, as these cannot be reduced and require definitive surgical intervention for optimal outcomes in terms of morbidity, mortality, and quality of life. 1

Understanding Fourth Degree Hemorrhoids

Fourth-degree hemorrhoids are defined as prolapsed internal hemorrhoids that cannot be reduced back into the anal canal. They may include both internal and external components and are often confluent from the skin tag to the inner anal canal. Acutely thrombosed, incarcerated internal hemorrhoids and incarcerated, thrombosed hemorrhoids involving circumferential rectal mucosal prolapse are also classified as fourth-degree hemorrhoids. 1

Treatment Algorithm

First-line Treatment

• Surgical hemorrhoidectomy is the most effective treatment for fourth-degree hemorrhoids 1
• This is explicitly indicated for:
  • Symptomatic fourth-degree hemorrhoids
  • Mixed internal and external hemorrhoids that cannot be reduced
  • Acutely prolapsed, incarcerated, and thrombosed hemorrhoids 1

Surgical Options

1. Conventional Hemorrhoidectomy Techniques:

   • Open (Milligan-Morgan) technique: Internal and external components are excised and the skin is left open in a 3-leaf clover pattern that heals secondarily over 4-8 weeks 1
   • Closed (Ferguson) technique: Each hemorrhoid component is excised and the wounds are closed primarily 1

2. Newer Surgical Approaches:

   • Stapled hemorrhoidopexy: Associated with less postoperative pain but has higher recurrence rates compared to conventional hemorrhoidectomy 2
   • Hemorrhoidal artery ligation: May be useful in less severe cases but not typically recommended as first-line for fourth-degree hemorrhoids 3

Evidence-Based Comparison of Techniques

• Effectiveness: Conventional hemorrhoidectomy has the highest success rate and lowest recurrence rate for fourth-degree hemorrhoids 1
• Pain management:
  • Stapled hemorrhoidopexy is associated with less postoperative pain 2
  • Open technique may have less discomfort in the early postoperative period compared to closed technique 4
• Recovery time:
  • Healing time is shorter with closed technique (2.8 weeks vs 3.5 weeks) 4
  • However, operating time is shorter with open technique (35 vs 45 minutes) 4

Important Considerations and Potential Complications

• Approximately 10% of patients may experience complications after standard hemorrhoidectomy 5
• Potential complications include:
  • Bleeding (early or delayed)
  • Urinary retention
  • Pain
  • Anal stenosis
  • Fissure
  • Fistula formation
  • Abscess
  • Incontinence in rare cases 5, 6

Special Circumstances

For patients with acutely prolapsed, incarcerated, and thrombosed hemorrhoids, two approaches may be considered:

1. Complete hemorrhoidectomy
2. Excision of the external component with rubber band ligation of the internal hemorrhoids 1

Caution

• Manual dilatation of the anus is not recommended due to the risk of sphincter injury and incontinence 1
• Laser hemorrhoidectomy offers no advantage over conventional techniques and is more costly 1
• Cryotherapy has a high complication rate and is no longer recommended 1

Proper patient selection and surgical technique are crucial to minimize complications and ensure optimal outcomes for patients with fourth-degree hemorrhoids.