What is the treatment for hemorrhoids and peri-rectal fissures?

Treatment of Hemorrhoids and Perirectal Fissures

The most effective treatment approach for hemorrhoids and perirectal fissures begins with conservative management, including increased fiber intake (25-30g daily), adequate hydration, sitz baths 2-3 times daily, and avoiding straining during defecation, with surgical intervention reserved for high-grade hemorrhoids or when conservative measures fail. 1

Diagnostic Approach

• A careful anorectal examination is essential for accurate diagnosis of both hemorrhoids and anal fissures 2
• External examination should look for:
  • External hemorrhoids, skin tags, thrombosed hemorrhoids
  • Anal fissures (best seen with eversion of the anal canal)
  • Signs of other pathology (perianal abscess, fistula)
• Anoscopy with adequate light source is necessary to evaluate internal hemorrhoids 2
• Further evaluation with flexible sigmoidoscopy or colonoscopy is indicated when:
  • Bleeding is atypical for hemorrhoids
  • No source is evident on anorectal examination
  • Patient has significant risk factors for colonic neoplasia 2

Classification of Hemorrhoids

Hemorrhoids are classified into four degrees 1:

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

Treatment of Hemorrhoids

Conservative Management (First-Line)

1. Dietary and Lifestyle Modifications:

   • Increased fiber intake (25-30g daily)
   • Adequate hydration
   • Sitz baths 2-3 times daily
   • Avoiding straining during defecation
   • Avoiding prolonged sitting
   • Regular physical activity 1

2. Medication:

   • Osmotic laxatives (polyethylene glycol 17g with 8oz water twice daily)
   • Stool softeners to prevent constipation 1

Procedural Treatment (For Persistent Symptoms)

• Rubber band ligation: First-line procedural treatment for grade I-III, resolves symptoms in 89% of patients 1
• Sclerotherapy: Alternative for grades I-II, short-term efficacy of 70-85% 1
• Infrared coagulation: Alternative for grades I-II, short-term efficacy of 70-80% 1
• Hemorrhoidal artery ligation: Useful for grade II-III hemorrhoids 1

Surgical Management

• Indicated for grade III-IV hemorrhoids that fail conservative and office-based treatments 1
• Options include:
  • Excisional hemorrhoidectomy: Gold standard for grade IV hemorrhoids 1
  • Ligasure hemorrhoidectomy: Minimally invasive option 3
  • Stapled hemorrhoidopexy: Minimally invasive option 3

Treatment of Anal Fissures

Conservative Management (First-Line)

1. Dietary and Lifestyle Modifications:

   • Increased fiber intake
   • Adequate hydration
   • Sitz baths 2-3 times daily
   • Avoiding straining during defecation 1, 4

2. Topical Treatments:

   • Topical nitrates
   • Calcium channel blockers 4

Surgical Management

• Indicated when conservative measures fail
• Options include:
  • Botox injection ± fissurectomy
  • Lateral internal sphincterotomy (LIS) 5, 4

Special Considerations

Patients with Inflammatory Bowel Disease

• Extreme caution with surgical interventions due to high rate of complications (41.2% for hemorrhoids and 57.1% for anal fissures) 5
• Conservative treatment strongly preferred 5

Immunocompromised Patients

• Higher infection risk with any procedure
• Careful evaluation and management required
• Consider antibiotics for perirectal abscess 6

Patients with Cirrhosis or Portal Hypertension

• Careful evaluation to distinguish hemorrhoids from rectal varices
• Standard hemorrhoidal treatments should not be used for varices 2, 1

Pregnant Women

• Conservative management preferred when possible
• Surgery only if absolutely necessary 1

Post-Procedure Care

• Pain management with NSAIDs
• Fiber supplements
• 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%)
  • Anal stenosis (0-6%) 1

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure bleeding is from hemorrhoids and not rectal varices or colorectal cancer 1
2. Attributing anal pain solely to hemorrhoids: Anal pain is generally not associated with uncomplicated hemorrhoids and suggests other pathology (e.g., thrombosis, fissure, abscess) 2
3. Inadequate evaluation: Never omit careful physical examination when a patient has anorectal symptoms 2
4. Overtreatment: Avoid surgical intervention for low-grade hemorrhoids that can be managed conservatively 1, 3
5. Undertreatment: Don't delay appropriate surgical referral for high-grade or complicated hemorrhoids 1