What is the recommended management for fourth degree hemorrhoids?

Management of Fourth Degree Hemorrhoids

Surgical hemorrhoidectomy is the recommended treatment for fourth-degree hemorrhoids due to its effectiveness and low recurrence rate. 1

Understanding Fourth Degree Hemorrhoids

Fourth-degree hemorrhoids are defined as internal hemorrhoids that have prolapsed and cannot be reduced back into the rectum. This represents the most advanced stage in the classification system of hemorrhoids:

• First-degree: Bleed but do not protrude
• Second-degree: Protrude with defecation but reduce spontaneously
• Third-degree: Protrude and require manual reduction
• Fourth-degree: Protrude and cannot be reduced 1

Treatment Algorithm for Fourth Degree Hemorrhoids

First-line Treatment: Surgical Hemorrhoidectomy

Conventional hemorrhoidectomy is clearly indicated for fourth-degree hemorrhoids based on the American Gastroenterological Association guidelines. The indications specifically include:

1. Symptomatic fourth-degree hemorrhoids
2. Mixed internal and external hemorrhoids that cannot be reduced
3. Acutely prolapsed, incarcerated, and thrombosed hemorrhoids 1

Surgical Techniques

Several surgical techniques are available:

1. Open (Milligan-Morgan) hemorrhoidectomy: The internal and external components of each hemorrhoid are excised and the skin is left open in a 3-leaf clover pattern that heals secondarily over 4-8 weeks 1

2. Closed (Ferguson) hemorrhoidectomy: Each hemorrhoid component is excised and the wounds are closed primarily 1

3. Stapled hemorrhoidopexy: A newer procedure that is associated with less postoperative pain than conventional techniques, though it has a higher recurrence rate for fourth-degree hemorrhoids 1, 2

Important Considerations

• Pain management: Postoperative pain is the major drawback of excisional hemorrhoidectomy. Narcotic analgesics are generally required, and most patients do not return to work for 2-4 weeks following surgery 1

• Recovery time: The mean hospital stay is typically 1-2 days, but full recovery may take several weeks 3

• Complications: Approximately 10% of patients may experience complications after standard hemorrhoidectomy, including bleeding, fissure, fistula, abscess, stenosis, urinary retention, soiling, or incontinence 4

Alternative Treatments

While these alternatives exist, they are generally not first-line for fourth-degree hemorrhoids:

1. Stapled hemorrhoidopexy: Although it offers faster recovery and less pain, it has higher recurrence rates for fourth-degree hemorrhoids and is generally better suited for third-degree hemorrhoids 2

2. Transanal hemorrhoidal dearterialization (THD): Some studies suggest this may be effective in selected cases of fourth-degree hemorrhoids, but it's not yet considered standard treatment 5

Common Pitfalls and Caveats

• Avoid manual dilatation of the anus: This approach has been associated with sphincter injuries and high rates of incontinence (52% in long-term follow-up) 1

• Avoid laser hemorrhoidectomy: It offers no advantage over conventional techniques and is associated with impaired wound healing and higher costs 1

• Urinary retention: This is a common complication (5.8-14.3%) that may require catheterization 3, 5

• Delayed hemorrhage: Can occur 7-10 days postoperatively and may require additional intervention 6

• Proper patient selection: Ensure that other anorectal conditions are not misdiagnosed as hemorrhoids, as this could lead to inappropriate treatment 1

By following these evidence-based recommendations, the management of fourth-degree hemorrhoids can be optimized to improve patient outcomes and minimize complications.