What is the role of hyaluronidase (hyalase) in surgery for strangulated hemorrhoids?

Use of Hyaluronidase in Strangulated Hemorrhoid Surgery

Hyaluronidase should be used as a submucosal infiltration agent to reduce edema and facilitate manual reduction in strangulated hemorrhoids, but only as part of conservative management prior to surgery—not during the surgical procedure itself. 1

Role in Non-Operative Management of Strangulated Hemorrhoids

The World Society of Emergency Surgery (WSES) guidelines specifically describe hyaluronidase as one of the established techniques for non-operative management of incarcerated and strangulated anorectal conditions. 1

Mechanism and Application

• Hyaluronidase works by depolymerizing hyaluronic acid in the extracellular matrix, creating microscopic spaces that allow edema fluid trapped in the third space to drain, thereby decreasing tissue swelling. 1

• The enzyme should be administered via submucosal infiltration into the edematous prolapsed or strangulated hemorrhoidal tissue. 1

• Administration must be performed with the patient in Trendelenburg position and under analgesia or mild sedation/anesthesia to facilitate subsequent manual reduction. 1

Clinical Context and Timing

• Hyaluronidase is indicated only when attempting conservative reduction of strangulated hemorrhoids WITHOUT signs of gangrene or perforation. 1

• The goal is to reduce edema sufficiently to allow manual reduction, thereby converting an emergency situation into an elective surgical case performed under optimal conditions. 1

• If signs of ischemia, gangrene, perforation, or hemodynamic instability are present, conservative measures including hyaluronidase should NOT delay immediate surgical intervention. 1

NOT Indicated During Surgical Hemorrhoidectomy

The available evidence does not support the use of hyaluronidase during the actual surgical excision of strangulated hemorrhoids. 1

• Emergency hemorrhoidectomy for incarcerated, gangrenous hemorrhoids can be performed safely without hyaluronidase, with results comparable to elective procedures. 1

• Pain management strategies during hemorrhoidectomy focus on topical muscle relaxants, local anesthetics at the operative site, and postoperative analgesics—not hyaluronidase. 1

Safety Considerations and Contraindications

Allergic Reactions

• Cross-reactivity exists between bee venom and hyaluronidase; the agent is absolutely contraindicated in patients with bee sting allergy. 1

• Most allergic reactions are immediate hypersensitivity reactions, though delayed reactions can occur. 2

• Skin testing may be considered before use if allergy history is uncertain, though it cannot predict all delayed reactions. 1, 2

Other Adverse Effects

• Bruising and swelling at the injection site are common minor adverse effects. 3

• Anaphylaxis is rare but possible, requiring appropriate monitoring and resuscitation equipment availability. 3

Practical Algorithm for Use

Step 1: Patient Assessment

• Confirm strangulated hemorrhoids without signs of gangrene, perforation, or hemodynamic instability. 1
• Verify no history of bee venom allergy. 1

Step 2: Patient Positioning and Preparation

• Place patient in Trendelenburg position. 1
• Administer appropriate analgesia or mild sedation/anesthesia. 1

Step 3: Hyaluronidase Administration

• Perform submucosal infiltration of hyaluronidase into edematous hemorrhoidal tissue. 1
• Allow time for edema reduction (typically 15-30 minutes based on general surgical practice).

Step 4: Attempt Manual Reduction

• Perform gentle manual reduction of the strangulated hemorrhoids. 1

Step 5: Outcome-Based Decision

• If reduction successful: Schedule elective definitive surgery under optimal conditions. 1
• If reduction fails: Proceed immediately to emergency surgical hemorrhoidectomy without further delay. 1

Important Caveats

• The failure rate of non-operative management for incarcerated hemorrhoids is high, so hyaluronidase use should never delay necessary surgical treatment. 1

• Hyaluronidase has no established role in routine elective hemorrhoid surgery or in managing thrombosed (non-strangulated) external hemorrhoids. 1

• The evidence for hyaluronidase in proctology is limited to case reports and expert consensus—no randomized trials exist specifically for hemorrhoidal applications. 1

• Alternative edema-reduction techniques include topical sugar application, hypertonic solutions (50% dextrose or 70% mannitol), and elastic compression wrapping, though these have similarly limited evidence. 1