Why are grade IV hemorrhoids not treated with immediate surgery?

Why Grade IV Hemorrhoids Are Not Treated with Immediate Surgery

Grade IV hemorrhoids are not immediately treated with surgery because conservative management must be attempted first to reduce inflammation, edema, and tissue congestion, which significantly improves surgical outcomes and reduces complications when surgery eventually becomes necessary. 1

Initial Conservative Management is Mandatory

Even for grade IV hemorrhoids, the treatment algorithm begins with conservative measures because:

• Acute inflammation and edema must be reduced before any intervention to minimize surgical complications and improve tissue handling during eventual hemorrhoidectomy 1, 2
• First-line therapy includes increased fiber (5-6 teaspoonfuls psyllium with 600 mL water daily) and water intake to soften stool and reduce straining 1, 2
• Topical treatments provide symptomatic relief: 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours shows 92% resolution rates for acute symptoms 2
• Short-term topical corticosteroids (≤7 days maximum) reduce local inflammation but must be limited to avoid tissue thinning 2, 3

Specific Contraindications to Immediate Surgery

Acutely incarcerated or thrombosed grade IV hemorrhoids represent a surgical emergency scenario, but even these require initial medical optimization unless tissue necrosis is present: 1

• Severe edema and inflammation make tissue planes difficult to identify, increasing risk of sphincter injury 1
• Acute thrombosis requires 72-hour window assessment: if presenting within 72 hours, excision under local anesthesia is appropriate; beyond 72 hours, conservative management is preferred as spontaneous resolution has begun 1, 2
• Immunocompromised patients have increased infection risk and require medical stabilization before any surgical intervention 1, 4

When Surgery Becomes Indicated

Surgery is indicated for grade IV hemorrhoids after conservative management fails, or when specific complications occur: 1

• Failure of medical and non-operative therapy after adequate trial (typically 4-8 weeks) 1, 3
• Persistent bleeding causing anemia (hemoglobin drop requiring transfusion consideration) 2
• Irreducible prolapse with tissue compromise or necrosis 1
• Mixed internal and external hemorrhoids with extensive symptomatic external component 1
• Concomitant conditions requiring surgery (fissure, fistula) 1

Surgical Approach for Grade IV Disease

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) remains the gold standard for grade IV hemorrhoids, with recurrence rates of only 2-10%: 2, 5

• Ferguson (closed) technique with primary wound closure shows superior outcomes regarding postoperative pain and healing compared to open technique 2, 6
• Postoperative pain is the major drawback, requiring narcotic analgesics with most patients unable to return to work for 2-4 weeks 1, 2
• Stapled hemorrhoidopexy may be considered for circular grade IV prolapse but has higher recurrence rates than conventional hemorrhoidectomy 6, 7

Critical Pitfalls to Avoid

Never perform these procedures for grade IV hemorrhoids: 1, 2

• Anal dilatation causes 52% incontinence rate at 17-year follow-up and should be completely abandoned 1, 2
• Simple incision and drainage leads to persistent bleeding and higher recurrence rates 2, 3
• Cryotherapy causes prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 2
• Rubber band ligation is contraindicated for grade IV hemorrhoids as it does not address the extensive prolapse and external component 1

Special Populations Requiring Modified Approach

Certain patient populations require additional considerations before surgery: 3, 4

• Pregnant patients: hemorrhoids occur in 80% during third trimester; safe treatments include fiber, fluids, and hydrocortisone foam, with surgery deferred until postpartum unless tissue necrosis occurs 2
• Patients on antithrombotic agents require medication adjustment and hematology consultation before hemorrhoidectomy 8
• Cirrhosis or portal hypertension patients have increased bleeding risk and require gastroenterology consultation 8
• Immunocompromised patients (AIDS, neutropenia, uncontrolled diabetes) have 5-fold increased risk of necrotizing pelvic sepsis after any hemorrhoid procedure 1, 4

The Clinical Triad Requiring Emergency Surgery

Severe pain, high fever, and urinary retention after any hemorrhoid treatment suggests necrotizing pelvic sepsis, requiring emergency examination under anesthesia with radical debridement of all necrotic tissue: 1, 4