What is the role of Diosmin (flavonoid) and Hesperidine (flavanone glycoside) in post-operative hemorrhoidectomy patients?

Diosmin-Hesperidin in Post-Hemorrhoidectomy Patients

Diosmin-hesperidin (micronized purified flavonoid fraction) should be administered postoperatively at 1000 mg twice daily for 7 days, then 1000 mg daily for up to 2 months, as it significantly reduces secondary bleeding risk and accelerates pain resolution after hemorrhoidectomy. 1, 2

Evidence for Postoperative Use

Bleeding Reduction

• Postoperative diosmin-hesperidin (Daflon 500 mg, containing diosmin 450 mg and hesperidin 50 mg) reduces secondary bleeding from 6.1% to 0.9% (p=0.03) when given for 1 week after hemorrhoidectomy. 1
• All bleeding episodes occurred between days 6-15 postoperatively, the critical period when eschar sloughs, making prophylactic coverage during this window particularly important. 1
• The number needed to treat is approximately 19 patients to prevent one bleeding episode. 1

Pain Management

• Oral flavonoids, including diosmin-hesperidin, are associated with significant reduction in post-hemorrhoidectomy pain when administered postoperatively. 2
• In hemorrhoidal disease generally, diosmin achieves 79% pain reduction in the first week and 98% by the second week of treatment. 3

Recommended Dosing Protocol

Immediate Postoperative Period (Days 1-7)

• Administer diosmin-hesperidin 1000 mg (two 500 mg tablets) twice daily for the first 7 days to cover the highest-risk period for secondary bleeding. 1, 3

Extended Recovery Period (Weeks 2-8)

• Continue diosmin-hesperidin 1000 mg once daily for up to 2 months to support complete wound healing and symptom resolution. 3

Mechanism of Action in Postoperative Setting

• Diosmin-hesperidin works through veno-active properties that reduce venous stasis and improve microcirculation in the hemorrhoidal plexus. 4
• The medication decreases local edema formation, which is particularly beneficial during the inflammatory phase of wound healing. 5
• Flavonoids strengthen venous walls and reduce capillary permeability, directly addressing the vascular pathophysiology that contributes to postoperative bleeding. 4

Safety Profile

• No side effects were reported in the randomized controlled trial of 228 post-hemorrhoidectomy patients. 1
• Excellent tolerability makes this medication easy to prescribe alongside standard postoperative regimens including analgesics and laxatives. 3

Integration with Standard Postoperative Care

• Diosmin-hesperidin should be added to, not substituted for, standard postoperative management including narcotic analgesics, stool softeners, and sitz baths. 6, 1
• The medication does not interfere with other postoperative interventions and can be safely combined with topical treatments. 1

Clinical Context and Limitations

While the American Gastroenterological Association guidelines discuss various strategies to reduce post-hemorrhoidectomy pain (including surgical technique modifications, local anesthetics, and topical agents), they do not specifically address diosmin-hesperidin. 6 However, the World Journal of Emergency Surgery recognizes flavonoids as useful for symptom relief in hemorrhoidal disease. 7

The strongest evidence for diosmin-hesperidin comes from a well-designed randomized controlled trial showing statistically significant reduction in the most serious postoperative complication—secondary bleeding—which can lead to emergency department visits, readmissions, and rarely, significant morbidity. 1

Important Caveats

• The primary benefit is bleeding prevention rather than pain control, though pain reduction is a secondary benefit. 1, 2
• Symptom recurrence reaches 80% within 3-6 months after cessation when used for chronic hemorrhoidal disease, but this is less relevant in the postoperative setting where the goal is supporting acute wound healing. 7
• This medication addresses the vascular component of healing but does not replace proper surgical technique or other evidence-based postoperative interventions. 6