How to treat incarcerated hemorrhoids?

Treatment of Incarcerated Hemorrhoids

Surgical intervention is the recommended treatment for incarcerated hemorrhoids (fourth-degree hemorrhoids), as these permanently prolapsed hemorrhoids cannot be reduced and require definitive management. 1

Classification and Diagnosis

Incarcerated hemorrhoids are classified as fourth-degree hemorrhoids in the Banov classification system. These are characterized by:

• Permanently prolapsed internal hemorrhoids that cannot be reduced
• May include both internal and external components
• May become thrombosed or gangrenous if left untreated 2, 1

Before proceeding with treatment, proper diagnosis is essential and should include:

• External examination to confirm irreducible prolapse
• Anoscopy with adequate light source to evaluate the extent of the condition
• Assessment for concomitant conditions (20% of hemorrhoid patients have anal fissures) 2

Treatment Algorithm

1. Immediate Management

• Pain control with NSAIDs and topical analgesics
• Sitz baths to reduce swelling and discomfort
• Ice packs to reduce edema
• Stool softeners to prevent further irritation during defecation 3

2. Definitive Treatment

For incarcerated (fourth-degree) hemorrhoids, surgical intervention is required:

Surgical Options:

1. Excisional Hemorrhoidectomy (preferred for incarcerated hemorrhoids)

   • Open (Milligan-Morgan) technique: Excision of hemorrhoidal tissue with wounds left open
   • Closed (Ferguson) technique: Excision with primary closure of wounds
   • Success rate: Highest among all treatments with lowest recurrence (2-10%)
   • Recovery time: 4-8 weeks 1, 4

2. Stapled Hemorrhoidopexy

   • Alternative to conventional excision
   • Advantages: Less postoperative pain, faster recovery
   • Disadvantages: Higher recurrence rate compared to excisional techniques
   • Not ideal for gangrenous or thrombosed incarcerated hemorrhoids 1, 5

Special Considerations

Thrombosed Incarcerated Hemorrhoids

If the incarcerated hemorrhoid is also thrombosed:

• Urgent surgical intervention is recommended
• Excisional hemorrhoidectomy is preferred over stapled techniques 1, 6

High-Risk Patients

Exercise caution in:

1. Pregnant women: Consider conservative management when possible; surgery only if absolutely necessary
2. Immunocompromised patients: Higher risk of infection; require careful perioperative management
3. Patients on anticoagulants: May need medication adjustment before surgery
4. Patients with portal hypertension/cirrhosis: Distinguish between hemorrhoids and rectal varices; standard hemorrhoidal treatments should not be used for varices 2, 1, 6
5. Patients with inflammatory bowel disease: High rate of postoperative complications 1

Postoperative Care

• Pain management: NSAIDs, narcotics as needed, fiber supplements, topical antispasmodics
• Sitz baths 2-3 times daily
• Stool softeners to prevent constipation
• Monitor for complications: bleeding (0.03-6%), urinary retention (2-36%), infection (0.5-5.5%)
• Long-term follow-up to assess for recurrence or anal stenosis (0-6%) 1, 7

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure the condition is truly incarcerated hemorrhoids and not rectal prolapse or rectal varices
2. Delayed treatment: Incarcerated hemorrhoids can become gangrenous if treatment is delayed
3. Inadequate pain control: Postoperative pain is significant and requires multimodal analgesia
4. Overlooking concomitant conditions: Check for anal fissures, abscesses, or other pathology
5. Inappropriate surgical technique: Choose the appropriate surgical approach based on the specific presentation and patient factors 2, 1

Remember that while conservative measures are appropriate for lower-grade hemorrhoids, incarcerated (fourth-degree) hemorrhoids require surgical intervention for definitive treatment and to prevent serious complications.