What are the approaches for hemorrhoid removal?

Approaches for Hemorrhoid Removal

Hemorrhoid management should follow a stepwise approach, starting with conservative measures for all grades, progressing to office-based procedures for grades I-III, and reserving surgical interventions for advanced or refractory cases. 1

Classification and Initial Assessment

• Hemorrhoids are classified as internal (above dentate line) or external (below dentate line) 1
• Internal hemorrhoids are graded I-IV based on prolapse severity:
  • Grade I: Bleeding without prolapse
  • Grade II: Prolapse with spontaneous reduction
  • Grade III: Prolapse requiring manual reduction
  • Grade IV: Irreducible prolapse 1, 2

Conservative Management (First-Line)

• Conservative management is first-line for all hemorrhoid grades and includes:
  • Increased dietary fiber and water intake to soften stool and reduce straining 1
  • Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) 1
  • Topical analgesics for pain and itching relief 1
  • Short-term topical corticosteroids (≤7 days) to reduce local inflammation 1, 3
  • Flavonoids to improve venous tone and relieve symptoms 3, 2
  • Regular sitz baths (warm water soaks) to reduce inflammation 1

Office-Based Procedures

• For grade I-III internal hemorrhoids not responding to conservative management:
  • Rubber band ligation is most effective (success rates 70.5-89%), placing a band around hemorrhoid base to restrict blood flow 1, 2
  • Injection sclerotherapy is suitable for grade I-II, using sclerosing agents to cause fibrosis (70-85% short-term success) 1, 2
  • Infrared photocoagulation uses heat to coagulate hemorrhoidal tissue (70-80% success) 2
  • Bands must be placed at least 2 cm above dentate line to avoid severe pain 1
  • Contraindicated in immunocompromised patients due to infection risk 1, 3

Surgical Management

• Indicated for:

  • Failure of conservative and office-based treatments
  • Symptomatic grade III-IV internal hemorrhoids
  • Mixed internal and external hemorrhoids 1, 3

• Surgical options include:

  • Conventional excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson techniques) with lowest recurrence (2-10%) but more pain 1, 2
  • Stapled hemorrhoidopexy elevates grade III-IV hemorrhoids to normal position 2, 4
  • Hemorrhoidal artery ligation for grade II-III with less pain and faster recovery 4
  • Newer techniques using diathermic or ultrasonic cutting devices may decrease bleeding and pain 4

Management of Thrombosed External Hemorrhoids

• For presentation within 72 hours: excision under local anesthesia provides faster pain relief 1, 5
• For presentation after 72 hours: conservative management with stool softeners, oral and topical analgesics 1, 5
• Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence 1, 5
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective 1, 5

Special Considerations

• Pregnancy: Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents, osmotic laxatives, and hydrocortisone foam 1
• Immunocompromised patients: Increased risk for infections, especially after rubber band ligation 1, 3
• Recurrent thrombosis: Consider referral to colorectal surgeon 3
• Ruptured thrombosed hemorrhoid: Clean gently, apply direct pressure for bleeding, continue conservative measures 5

Important Caveats

• Avoid assuming all anorectal symptoms are due to hemorrhoids; other conditions may coexist 1
• Avoid long-term use of high-potency corticosteroids (>7 days) due to tissue thinning 1, 5
• Anal dilatation is not recommended due to high rates of incontinence (52% at 17-year follow-up) 1, 3
• Cryotherapy is rarely used due to prolonged pain and foul-smelling discharge 1, 3
• Laser hemorrhoidectomy offers no advantage over conventional techniques and is more costly 3