Can a grade 4 hemorrhoid recede on its own after lancing or is surgical hemorrhoidectomy required?

Management of Grade 4 Hemorrhoids After Lancing

Surgical hemorrhoidectomy is required for grade 4 hemorrhoids as they will not recede on their own after simple lancing, due to their extensive nature and permanent prolapse. 1

Understanding Grade 4 Hemorrhoids

Grade 4 hemorrhoids are characterized by:

• Permanent prolapse that cannot be manually reduced
• Significant tissue changes that prevent spontaneous resolution
• Often accompanied by external components

Treatment Algorithm for Grade 4 Hemorrhoids

First-line Treatment

• Surgical hemorrhoidectomy is the definitive treatment for grade 4 hemorrhoids 2, 1
• Simple lancing (incision and drainage) only addresses thrombosis but does not resolve the underlying prolapse

Surgical Options for Grade 4 Hemorrhoids

1. Excisional Hemorrhoidectomy:

   • Ferguson technique (closed): Excision with wound closure
   • Milligan-Morgan technique (open): Excision without wound closure
   • Both techniques have similar pain profiles but closed technique may have faster healing 2
   • Recurrence following properly performed hemorrhoidectomy is uncommon 2

2. Stapled Hemorrhoidopexy:

   • Faster recovery than traditional excisional methods 3
   • Higher recurrence rates compared to excisional hemorrhoidectomy 4
   • Not ideal for all grade 4 cases, especially those with significant external components

3. Transanal Hemorrhoidal Dearterialization:

   • May be considered for selected cases
   • Similar effectiveness to stapled hemorrhoidopexy 4

Why Lancing Alone Is Insufficient

Lancing (incision and drainage) only addresses acute thrombosis but does not:

• Correct the underlying anatomical prolapse
• Address the vascular and structural changes in grade 4 hemorrhoids
• Provide long-term resolution of symptoms

Important Clinical Considerations

• Pain Management: Postoperative pain is a significant concern with excisional hemorrhoidectomy

  • Narcotic analgesics are typically required
  • Most patients require 2-4 weeks for recovery 2

• Surgical Selection: The choice of surgical technique should consider:

  • Circumferential nature of the disease
  • Size of hemorrhoids
  • Predominant symptoms 5

• Recovery Expectations:

  • Patients should be informed about expected recovery time
  • Ferguson hemorrhoidectomy has shown high patient satisfaction rates (624/693 patients reporting good satisfaction after 2 weeks) 6

Common Pitfalls to Avoid

• Delaying definitive treatment: Grade 4 hemorrhoids will not resolve with conservative measures alone
• Attempting office-based procedures: Rubber band ligation, infrared coagulation, and sclerotherapy are ineffective for grade 4 hemorrhoids 1, 7
• Inadequate pain control: Underestimating postoperative pain can lead to poor patient compliance and satisfaction

Special Considerations

• Patients with inflammatory bowel disease: Exercise extreme caution with surgical interventions; conservative management strongly preferred 1
• Immunocompromised patients: Require careful monitoring due to increased infection risk 1
• Patients on antithrombotic agents: May need medication adjustment before surgery 1

In conclusion, while less invasive procedures are preferred for lower-grade hemorrhoids, grade 4 hemorrhoids require surgical hemorrhoidectomy for definitive treatment, as they will not recede on their own after simple lancing.