Nonsurgical treatment options for internal hemorrhoids

Nonsurgical treatment options for internal hemorrhoids – includes patient information sheets

John L. Pfenninger

Over 75 percent of persons in the United States have hemorrhoids at some time during their life, and an estimated 50 percent of those over the age of 50 years require some type of conservative or operative therapy.(1) In the past, when topical treatments failed to control symptoms, treatment progressed to surgery. Surgical excision was associated with significant pain, a four- to six-week absence from work and substantial hospital costs. Because of the embarrassment and inconvenience associated with hemorrhoid treatment, many patients are reluctant to discuss symptoms with their physician.(2)

Previously, treatment modalities have been limited to topical medications, surgery and, more recently, sclerotherapy and rubber band ligation techniques. Now, infrared coagulation, low-voltage direct current and bipolar electrocoagulation techniques provide additional effective forms of outpatient therapy.(3)(4)(5)(6)(7)(8) Treatment with these newer modalities rarely requires that patients take time off from work. Continued symptom control depends on modification of diet, with the goal of increasing the bulk and obtaining a soft, but formed, stool.

Anatomy

Choice of treatment for internal hemorrhoids depends on the anatomic origin (above or below the dentate line) and the grade of disease. A brief review of the anatomy is helpful (Figure 1). The squamous epithelium of the outer skin changes to mucosal glandular epithelium at the dentate, or pectinate, line. This distinctly visible demarcation is analogous to the vermilion border of the mouth. It has special significance because the external pain fibers generally terminate at the dentate line. Most patients have no sensation above the dentate line and exquisite sensitivity below it. It is also the anatomic line that differentiates internal from external hemorrhoids. Treatment of internal hemorrhoids is generally painless while treatment of external hemorrhoids causes significant discomfort.

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The submucosa of the anal canal is rich in vasculature. Hemorrhoids consist of both arteries and veins(1) and are generally present at the right posterior, right anterior and left lateral positions. Both internal and external hemorrhoids occur in these locations. These anatomic designations are more helpful and consistent than location designations based on a clock model. Hemorrhoids are best visualized through use of an Ives slotted anoscope, with the patient in either the left lateral decubitus position or the jackknife position (Figure 2).

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Etiology

Numerous etiologies of hemorrhoids have been proposed, including increased hydrostatic pressure in the erect position on the hemorrhoidal system of vessels that lacks valves, intrinsic weakness of the blood vessel wall, excessive arterial flow, obstruction to outflow secondary to such conditions as pregnancy, and increased intra-abdominal pressure from many causes, including prolonged forceful Valsalva’s maneuver during defecation.(9) Interestingly, portal hypertension does not cause hemorrhoids and the development of hemorrhoids is generally not associated with obstructive neoplasms. Hemorrhoids are not just “varicose veins” since they do not contain valves, as do lower extremity veins. Dilated hemorrhoidal veins are found even in neonates, and given the widespread prevalence of hemorrhoidal veins among asymptomatic persons, it has been suggested that hemorrhoids are normal features of the human anal canal.

Although the exact cause of enlarged and symptomatic hemorrhoids is debated, it is known that hemorrhoids occur more frequently in persons with constipation who have small, hard, infrequent stools. Diarrhea can also cause hemorrhoids, and this cause is frequently seen in alcoholic patients.(10) A familial tendency toward development of hemorrhoids has also been noted.

Definitions

Hemorrhoids are dilated arteriovenous complexes.(1) It is important to note that hemorrhoids are classified as internal or external according to origin and not according to the final level of greatest protuberance (Figure 3). Internal hemorrhoids originate above the pectinate line and, even though they may protrude externally, are still classified as internal hemorrhoids. External hemorrhoids orginate below the dentate line. The term mixed hemorrhoids generally refers to confluent internal and external hemorrhoids. A thrombosed hemorrhoid is a hemorrhoid with a clot. These clots do not propagate proximally, and the patient is not at risk for thromboembolism. Clinically, most thrombosed hemorrhoids that are evaluated are external since they cause pain. Internal hemorrhoids thrombose but are generally painless. An external hemorrhoidal tag is a fibrotic mass of tissue of varying size that protrudes from the anus. The tag no longer has a large dilated vein but can become inflamed or cause problems with hygiene.(9)

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Grading of internal hemorrhoids depends on the amount of prolapse, or the extent to which the hemorrhoid descends into the anal canal and out of the anus (Figure 4). It is important to determine the grade since treatment modalities are often limited to particular grades of lesions. In grade I lesions, the hemorrhoidal tissue is present and identifiable but rarely symptomatic, although these lesions may become irritated and cause bleeding. Grade II hemorrhoids actually prolapse with a bowel movement but return spontaneously, while grade III hemorrhoids require manual replacement. With grade IV hemorrhoids, the tissue remains outside the anus despite all efforts to replace it.(11) In extreme cases, hemorrhoids can prolapse, become edematous and, with contraction of the anal sphincters, strangulation can occur. Rectal mucosa can become necrotic. These conditions are surgical emergencies.

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Symptoms

The most common symptoms of internal hemorrhoids are bleeding and a palpable, protruding mass. It is important to be aware that many other types of anorectal pathology may also present with bleeding and/or a mass. Anal fissures commonly cause pain that accompanies defecation and may be associated with small amounts of rectal bleeding. The pain is described as a “burning” or “tearing.” Perirectal abscesses are seen more frequently in patients with diabetes or other immunocompromising conditions. Such abscesses can be lifethreatening and require immediate incision and drainage. Anal fistulas can be a presenting symptom or complication of inflammatory bowel disease. Perineal condylomas often occur in the anal area, and local irritation can cause pain or bleeding. The possibility of anal or rectal carcinoma must always be kept in mind.

Hemorrhoidal bleeding from internal hemorrhoids is generally painless and occurs after passage of stool. An achiness or feeling of fullness after defecation may also be present. Pain is unusual unless thrombosis involving external tissue is present, and then the pain can be excruciating. The patient may even have trouble walking or sitting. Pain due to an anal fissure occurs during and after bowel movements, whereas pain associated with a thrombosed external hemorrhoid is constant.

Many patients attribute pruritus ani to hemorrhoids. However, hemorrhoids rarely produce significant itching. Pruritus ani has numerous other causes, including perianal dermatitis, candidiasis, pinworm infestation, human papillomavirus infection, lichenification with fine fissuring secondary to chronic scratching, excessive anal hygiene, eczema or allergic reactions, and others. Patients should not be misled into thinking that treatment of their hemorrhoids will eliminate pruritus.(1)

The presence of large external hemorrhoidal tags may occasionally pose a problem with anal hygiene, and this difficulty alone may warrant their removal. External tags that are asymptomatic do not need treatment, but care must be taken to differentiate an external tag from a pedunculated polyp or sentinel polyp from a fissure.

Rectal bleeding poses a particularly difficult diagnostic problem. Although bleeding may be the result of hemorrhoids, which are generally “benign,” occult colonic neoplasms must be taken into consideration as a possible source of bleeding. The literature suggests that each patient be evaluated independently to determine whether a more extensive colon work-up is needed.(12)

History and Physical Examination

A careful history is important to determine the most likely etiology of the symptoms and to guide subsequent examination and treatment. In addition to general factors, specific questions should be addressed. The entire history, physical examination, treatment and follow-up plan can be documented in a single encounter form (Figure 5). It is important to determine what the symptoms are to give the patient realistic expectations for treatment outcome.

Patient Encounter Form

Name: _____ Age: ___ Male/Female: ___ Date: ___

Subjective

Anal itching: Fecal incontinence:

Anal pain (with bowel movement or Protrusion:

between bowel movements): Weight loss:

Abdominal pain: History:

Bleeding (on toilet paper, with bowel Anoscopy

movement, or dripping): Sigmoidoscopy

Change in bowel habits: Barium enema

Patient has read and understood handouts:

Other:

Prior treatment:

Medical

Surgical

Objective

Abdominal examination (tenderness, mass, Anoscopic examination:

organomegaly): Fissure

External anal examination: Fistula

Redundant tissue Hemorrhoids

External hemorrhoidal tissue

Prolapse

Fissure

Fistula Right posterior Right anterior

Infection

Digital anal examination:

Masses

Tenderness

Prostate

Impression Left lateral

Plan

Patient education:

Diet

Hygiene

Control of symptoms

Treatment technique

Risks

Benefits

Complications

Treatment (infrared coagulation, direct current ablation, bipolar

coagulation, banding, surgical, other):

Flexible sigmoidoscopy indicated?

Scheduled?

Follow-up:

Physician’s signature _____ Date _____

Virtually all patients can be examined and treated while in the left lateral decubitus position with the knees drawn up toward the chest, in a lateral Sim’s position (Figure 2). The patient who presents with pain can apply a solution of 20 percent benzocaine (Hurricaine) to the anal area to achieve some degree of anesthesia before the examination. Visual inspection, with spreading of the glutei, is important to define the presence of dermatitis, mass, prolapsed hemorrhoid, thrombosis, or fissure.

A digital examination is carried out gently with a well-lubricated finger (using K-Y jelly or 5 percent lidocaine ointment). The digital examination is conducted to check for sphincter tone, mass, tenderness, prostate size (if applicable) and presence of blood on the glove on removal. It may be appropriate to test for occult blood at this time. Internal hemorrhoids, unless thrombosed, are generally not palpable. Sentinel tags from chronic fissures may be palpable. The presence of pain and a tight sphincter should alert the examiner to the possibility of a fissure.

Internal inspection (anoscopy) is carried out using an Ives slotted anoscope (Figure 6). Unless a proper instrument is used, lesions can easily be missed. The Ives instrument is ideal, as it not only provides an excellent exposure of the anoderm, but also allows hemorrhoidal tissue to protrude into the scope for identification.

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If patients present at a time when hemorrhoids are “under control,” the examination may reveal little compared with an examination performed when the lesions are flaring. Some evidence suggests that treating a lower grade lesion immediately with the modalities discussed here may be advantageous to waiting until the hemorrhoid has become advanced.(9)

Internal hemorrhoids occur more commonly at the right anterior, right posterior and left lateral locations, but may be found at any location. Fissures are generally found in the midline, both anteriorly and posteriorly. If a significant fissure occurs laterally, inflammatory bowel disease, tuberculosis or another pathologic process should be considered.(12)

All patients do not necessarily require evaluation with flexible sigmoidoscopy, but strong consideration should be given to examination of the descending colon to rule out any coexisting pathology.(12)

Indications and Contraindications for Treatment

Bleeding or other symptoms that persist despite conservative management, and that are determined to be the result of hemorrhoids, point to a need for destructive treatment. The mere presence of hemorrhoids does not demand treatment, since they are often found in completely asymptomatic individuals.

Contraindications to treatment are listed in Table 1. The patient must have reasonable expectations regarding the results of treatment and understand the risks, benefits and possible complications. A patient education handout about hemorrhoids and their treatment follows this article and, if given to the patient before surgery, can enhance communication and decrease anxiety.

TABLE 1 Contraindications to Outpatient Hemorrhoid Treatment

Acquired immunodeficiency syndrome or other significant immunodeficiency disorders

Coagulopathy

Inability to adequately assess anatomy

Inflammatory bowel disease

Pregnancy or immediately postpartum

Rectal wall prolapse

Significant anorectal fissure or infection

Suspected anorectal or colonic tumor

Uninformed or unreliable patient

Preparation for Treatment

An enema given before treatment, although not necessary, can help decrease patient embarrassment and aid visualization. Four 200-mg tablets of ibuprofen taken one hour before treatment can help reduce swelling and discomfort that may occur after the procedure; aspirin should be avoided. Administration of an anesthetic is not required before treatment of internal hemorrhoids but is essential before treatment of any external lesions. Two percent lidocaine with epinephrine is sufficient in patients with external hemorrhoids.

Treatment Modalities for Internal Hemorrhoids

GENERAL

The first line of treatment is a high-fiber diet with commercial fiber supplements and generous oral fluids to promote soft, but formed, regular bowel movements, in addition to use of sitz baths, proper anal hygiene and limited topical corticosteroid creams or foams.(9) Topical anesthetics may also be of benefit (e.g., 5 percent lidocaine ointment). When evaluated scientifically, many over-the-counter preparations are not considered efficacious, but many patients report great empiric benefit with their use. Patients should be advised against prolonged use of topical corticosteroids, which is potentially harmful.

When topical measures fail, specific treatment directed at the cause of the problem is indicated. If recurrence of hemorrhoids is to be avoided, it is important that the patient maintain soft stools after treatment. The long-term benefits of a highfiber diet, with adequate fluid intake, cannot be overemphasized.

Several professional organizations, such as the American Society of Colon and Rectal Surgeons,(13) have published guidelines on the treatment of hemorrhoids. Although recommendations differ, each of the various outpatient modalities is a reasonable approach to treatment when used on an appropriate grade of hemorrhoid. Equipment availability and user familiarity will often dictate treatment choice. Each approach has specific strengths, indications, technique, equipment and complications. Although infrared coagulation, bipolar electrocoagulation and low-voltage direct current coagulation are easy to use and are associated with infrequent complications, these newer modalities have only been slowly adopted in the United States.(3)(4)(5)(6)(7)(8) Subacute bacterial endocarditis prophylaxis is generally not recommended but should be an individual consideration.

Internal hemorrhoids in the same location are usually treated at the same time; hemorrhoids at other locations are treated on subsequent visits. In most cases, low-grade hemorrhoids at multiple sites could be treated during the same visit, but the rate of complications increases when more than one site is treated. Also, it is best, especially during the first visit, to gauge the patient’s tolerance. The first office visit includes evaluation and treatment with subsequent treatment follow-up visits at approximately monthly intervals. Complete treatment may require a total of two to four visits, depending on the extent and grade of disease. Grade III and IV lesions may require more than one treatment per location for complete resolution.

RUBBER BAND LIGATION

Band ligation, first popularized by Barron over 30 years ago, was one of the initial office procedures introduced to replace surgical excision of internal hemorrhoids. The real advantage of this technique is the low cost of the equipment ($250 to $400). This method is effective and remains the standard by which the newer methods are compared.

Required equipment includes the adapted McGivney ligator (available from most medical suppliers), long-handled alligator or Allis forceps, and high-tension, small-diameter rubber bands (Figure 7). A newer development, the McGown One Hand Ligator (George McGown, Pembrose Pines, Fla.), uses air suction and a thumb activator to draw the hemorrhoid tissue into the ligator. This obviates the need for long-handled forceps and frees a hand to hold and direct the anoscope.

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The technique of rubber band ligation is summarized in Figure 8. When the trigger on the ligator is pulled, the rubber band is forced off of the outer cylinder and onto the base of the hemorrhoid. The simultaneous placement of two bands in the event that one breaks during or after application has been advocated. After seven to 10 days, the strangulated tissue sloughs off, leaving an ulcer that heals over time.(14)

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Grade I hemorrhoids are not as easily treated with ligation. The clinician must avoid pulling too much of the mucosa into the drum to be ligated, which could cause excessive sloughing and prolonged healing. Although band ligation is easily mastered, it has the disadvantage of requiring two persons–the operator and the assistant who holds the anoscope in place.(1)(3)(6)(7)(8)(9)(15) Rare cases of perianal sepsis and death have been reported after banding of hemorrhoids.(16)

INFRARED COAGULATION

The Infrared Coagulator (Redfield Corporation, Montvale, N.J.) received clearance from the U.S. Food and Drug Administration for use in the treatment of hemorrhoids in 1984. It is simple to use, quick and provides results comparable to banding. This technique is best suited for treatment of grade I and II hemorrhoids, although it occasionally can be effective in the treatment of grade III lesions if additional treatments are provided.(3)(6)(8) One meta-analysis(8) that compared infrared coagulation, rubber band ligation and injection sclerotherapy showed that use of infrared coagulation was associated with both fewer and less severe complications and, when all factors were considered, appeared to be the optimal nonoperative treatment of the three compared.

The infrared coagulation device (Figure 9) focuses infrared light on hemorrhoidal tissues using a quartz glass rod tip, 6 mm in diameter. The light energy coagulates the tissue. The contact tip element is available in either sapphire or Teflon, both of which do not adhere to tissue. No special equipment, grounding or preparation is required. The probe is reusable and should be cold sterilized between patients.

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The technique includes passing the rod probe through the slotted anoscope and applying it lightly to the superior (base) portion of the hemorrhoid, above the dentate line. The hemorrhoid suspected of causing the most symptoms should be treated first. The unit is most frequently set at 1.0 to 1.5 seconds, and the trigger is pulled. The device has no “power” settings, just the timer. A white coagulum is created and a small amount of smoke may appear, accompanied by a “crackling sound.” Smoke will be produced only if debris is present on the contact tip. The tip is removed between each application, wiped clean with saline or alcohol and then reapplied. The moment the light goes out, the tip is cool. This is an important safety consideration. Three to six applications per hemorrhoid group are used.(14)

Patients may feel a warmth or a heat sensation just as the unit turns off, but this is generally well tolerated. However, if the contact tip is applied below the dentate line, the patient will experience significant pain. Treatment sites should not overlap. Treatment is quick and technique is easy to master.

BIPOLAR ELECTROCOAGULATION

The bipolar electrocoagulation device (Circon, Santa Barbara, Calif.) is an electrosurgical generator that uses a disposable probe, 17 cm long, with two active contacts located on the tip (Figure 10). A grounding pad is not required.

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Timing and power level are adjustable. A 2-second application is performed at 30 to 35 W or at level 6 or 7, which are common settings. The active portion of the probe (1.7 cm) is laid over the hemorrhoid, including the proximal (base) portion, and the unit is activated. Coagulation occurs and a white eschar is formed. Two to three applications may be necessary for each hemorrhoid site. The operator must be especially careful to apply the probe above the pectinate line.(14) It is somewhat difficult to determine the edge of the active electrode once it has been inserted through the anoscope. (Careful practice on beefsteak before clinical use will help the clinician locate this line.)

Although more than one area of hemorrhoids may be treated at the same visit, it may be best to treat one area at a time, with monthly follow-up treatments, until all hemorrhoids have resolved. The advantages of bipolar electrocoagulation are that it may be more efficacious for treatment of higher grade lesions, it is quick, and it is easy to master.(4)(7)(13)(17) A disadvantage is that it uses a disposable probe.

LOW-VOLTAGE DIRECT CURRENT

The Ultroid unit (Cabot Medical Corporation, Longhorne, Pa.) is a direct current generator with a disposable dual-probed tip (Figure 11). A reusable grounding pad and nonconductive anoscope included with the unit are required. The handpiece allows single-handed application since all controls, power settings and elapsed time display are located in the handpiece itself.

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The technique is similar to that of infrared coagulation and bipolar electrocoagulation. The probe is inserted gently into the mucosa at the base of the hemorrhoid through the nonconductive anoscope. The operator must be careful not to apply too much pressure, lest the sharp, fine-tipped probes penetrate deeply through the mucosa. The control button is activated and power is increased by 2 to 4 mA every 30 seconds, until the patient senses discomfort or electrical sensations. The probe is left in place, still activated, until the sensations cease, then power is increased again. This cycle is repeated until 12 to 16 mA are reached. The higher the amperage, the more rapid the treatment. The probe must remain in place for 8 to 14 minutes, depending on the grade of the hemorrhoid being treated.

When the unit is activated, tiny bubbles can be seen around the electrode sites and a “crackling” and “popping” sound can be heard. When the procedure is complete, the entire hemorrhoid will be white. One advantage of this technique is excellent control of any pain (if the patient experiences pain, the voltage should be reduced until the patient is comfortable for 30 to 60 seconds, and then the voltage should be increased again). Also, this unit can treat all grades of lesions.(14) The disadvantage is the amount of time required for each treatment,(4)(5) and use of a disposable probe.

SCLEROTHERAPY AND CRYOTHERAPY

Initially, phenol was used as a sclerosant in the treatment of hemorrhoids, but precise location was essential, complications were frequent and results were poor. Newer sclerosing agents have improved results, but the possibility of anaphylaxis and poor outcomes has hampered usage of sclerotherapy. Cryotherapy causes a prolonged discharge, which is unacceptable to most patients, and therefore, is not recommended. When compared with the newer modalities, sclerotherapy and cryotherapy offer few additional benefits.(1)(8)(14)

LASER THERAPY

Both carbon dioxide and neodymium: yttrium-aluminum-garnet (Nd:YAG) lasers are used for coagulation or excision of hemorrhoidal tissue. Equipment expense restricts this modality to larger multispecialty groups. Laser coagulation provides no distinct advantage over other methods. Bleeding and pain can occur if the depth and location of laser use are not carefully controlled.(18)

Postoperative Care

In general, patients return immediately to full activity after treatment. Activities such as weight lifting that cause excessive Valsalva’s maneuvers should be limited for two weeks. Stool should be kept soft. A return visit in four to six weeks may be beneficial for repeat evaluation. Rarely is any medication stronger than ibuprofen required for pain relief.

Complications

Treatment complications include pain (if probes or bands are applied low, near the innervated tissue at the dentate line), persistence of the hemorrhoid and bleeding. Bleeding is always a possibility and may begin immediately, and it may consist of either spotting or frank blood with clots. Commonly, bleeding occurs with or immediately after a bowel movement. At 10 to 14 days after treatment, when the eschar or tissue sloughs, bleeding may occur even in patients who previously had experienced none. For cases of minor bleeding, expectant observation is indicated. Monsel’s solution (ferric subsulfate) or electrocautery are rarely required to control bleeding.

Patients with postoperative infection may present with severe pain, fever and urinary retention.(13) The presence of any of these symptoms should prompt immediate reevaluation. Infection has been reported with rubber band ligation; infection has not been reported with infrared coagulation, bipolar coagulation or direct current ablation. Sepsis and death are very rare complications of rubber band ligation. Most patients will have some rectal discharge or bleeding after the procedure. Recurrence rates vary from 10 to 50 percent over five years of follow-up.(9)(19)(20) Proper bowel habits must be emphasized to minimize the risk of recurrence. Recurrent hemorrhoids can be treated using the same guidelines used in treating the initial lesions. Modern treatment of internal hemorrhoids offers numerous advantages over past available treatments.

A patient information handout on hemorrhoids is provided on page 839.

Figure 8 is adapted from McSwain NE. Banding of hemorrhoids. Emergency Medicine 1988; 20:87-8. Used with permission.

The authors thank Pat Wolfgram, Shirley Marsh and Joi Henton for their assistance in the preparation of this manuscript.

REFERENCES

(1.)Liebach JR, Cerda JJ. Hemorrhoids: modern treatment methods. Hosp Med 1991:53-68.

(2.)Bleday R, Pena JP, Rothenberger DA, Goldberg SM, Buls JG. Symptomatic hemorrhoids: current incidence and complications of operative therapy. Dis Colon Rectum 1992; 35:477-81.

(3.)Templeton JL, Spence RJ, Kennedy TL, et al. Comparison of infrared coagulation and rubber band ligation for first and second degree hemorrhoids. Am J Gastroenterol 1989; 84:475-81.

(4.)Jensen DM, Randall G, Machicado GA. Comparison of direct current (DC) vs BICAP probe for treatment of chronically bleeding internal hemorrhoids [Abstract]. Gastrointest Endosc 1988; 34:196.

(5.)Norman DA, Newton R, Nicholas GV. Direct current electrotherapy of internal hemorrhoids: an effective, safe, and painless outpatient approach. Am J Gastroenterol 1989; 84:482-7.

(6.)Zinberg SS, Stern DH, Furman DS, Wittles JM. A personal experience in comparing three nonoperative techniques for treating internal hemorrhoids. Am J Gastroenterol 1989; 84:488-92.

(7.)Griffith CD, Morris DL, Ellis I, Wherry DC, Hardcastle JD. Out-patient treatment of haemorrhoids with bipolar diathermy coagulation. Br J Surg 1987; 74:827.

(8.)Johanson JF, Rimm A. Optimal nonsurgical treatment of hemorrhoids: a comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy. Am J Gastroenterol 1992; 87:1600-6.

(9.)Schussman LC, Lutz LJ. Outpatient management of hemorrhoids. Prim Care 1986; 13:527-41.

(10.)Johanson JF, sonnenberg A. Constipation is not a risk factor for hemorrhoids; a case control study of potential etiological agents. Am J Gastroenterol 1994; 89:1981-6.

(11.)Dennison AR, Wherry DC, Morris DL. Hemorrhoids. Nonoperative management. Surg Clin North Am 1988; 68:1401-9.

(12.)Trilling JS, Robbins A, Meltzer D, Steinbardt S. Hemorrhoids: associated pathologic conditions in a family practice population. J Am Board Fam Pract 1991; 4:389-94.

(13.)Standards Task Force of American Society of Colon and Rectal Surgeons. Practice parameters for the treatment of hemorrhoids. Dis Colon Rectum 1993; 36:1118-20.

(14.)Zainea G, Randall G, Norman DA, Pfenninger JL. Office treatment of hemorrhoids. In: Pfenninger JL, Fowler GC, eds. Procedures for primary care physicians. St. Louis: Mosby, 1994.

(15.)Dennison AR, Whiston RJ, Rooney S, Morris DL. The management of hemorrhoids. Am J Gastroenterol 1989; 84:475-81.

(16.)Russell TR, Donohue JH. Haemorrhoidal banding. A warning. Dis Colon Rectum 1985; 28:291-3.

(17.)Yang R, Migikovsky B, Peicher J, Laine L. Randomized, prospective trial of direct current versus bipolar electrocoagulation for bleeding internal hemorrhoids. Gastrointest Endosc 1993; 39:766-9.

(18.)Smith LE. Hemorrhoidectomy with lasers and other contemporary modalities. Surg Clin NA 1992; 72:665-79.

(19.)Walker AJ, Leicester RJ, Nicholls RJ, Mann CV. A prospective study of infrared coagulation, injection and rubber band ligation in the treatment of hemorrhoids. Int J Colorectal Dis 1990; 5(2):113.

(20.)Weinstein SJ, Rypins EB, Houck J, Thrower S. Single session treatment for bleeding hemorrhoids. Surg Gynecol Obstet 1987; 165:479-82.

RELATED ARTICLE: Nonsurgical Treatment of Hemorrhoids

Hemorrhoids–enlarged veins in the rectum–are a very common complaint. Women often get hemorrhoids during pregnancy, but these hemorrhoids usually go away after childbirth. Men often have more problems with hemorrhoids and need treatment more often than women.

Most of the time, hemorrhoids can be treated without surgery. Surgical removal of hemorrhoids, called hemorrhoidectomy, is only used rarely in the most advanced cases. You must be admitted to the hospital for this surgery.

There are various ways to treat hemorrhoids without surgery. These procedures can be performed in your doctor’s office and usually don’t require time off from work. The recovery period for people who have one of these treatments is usually very short, often no more than a few days. The procedures that may be used are described below:

* Rubber band ligation is used by many doctors. With this technique, your doctor uses a device to place one or two small rubber bands securely around the base of the hemorrhoid. The rubber bands are left in place to close off the blood supply to the hemorrhoid. The bands and hemorrhoid fall off after seven to 10 days, leaving a small sore that heals over time.

* Infrared coagulation (also called IRC) uses four or five 1.5-second applications of infrared light to close off the blood supply to the hemorrhoid. If you have more than one hemorrhoid, you will need additional treatments, since only one area is treated during each visit. Although you might feel a little warmth during the treatment, there’s not much pain. You may have a little bleeding between the fourth and 10th days after the procedure. If you need additional treatments, you will need to return to your doctor in about one month.

* Direct current ablation (also called Ultroid) is used on large hemorrhoids. A small probe is inserted into the hemorrhoid, and very low levels of electrical power are applied for six to 10 minutes. The electrical current closes off the blood supply to the hemorrhoid. There isn’t much pain with this treatment. Since only one group of hemorrhoids is treated at a time, you may need to return for additional treatments.

* Electrocoagulation diathermy (also called Bicap) uses a special probe for two seconds to apply electrical current to close off the blood supply to the hemorrhoid. This procedure is similar to infrared coagulation and direct current ablation.

* Radiofrequency ablation uses a very high frequency radiowave to remove external skin tage. Skin tage are loose skin that is left after a hemorrhoid has gone away. You will need a shot with numbing medicine before the procedure. The radiofrequency ablation technique takes about 15 minutes. Because this technique involves removal of skin, the treated area will be tender for about two to three weeks, or until the area is healed.

Things to Do Before Treatment

Here are some things you can do to prepare yourself for treatment:

* One hour before the procedure, use an enema. Hold the enema solution inside you for five to 10 minutes and then expel it. (Prepared enemas are available without a prescription at pharmacies, but a tap-water enema will work just as well. Don’t add soap to the enema if you use plain tap water.)

* For pain relief, take four ibuprofen tablets (Advil), 200 mg each, about one hour before the procedure.

* Don’t take any aspirin for 10 days after the procedure.

* Take a stool softener, such as Metamucil or Citrucel, every day for a few days before the procedure. Don’t overdo it! You just need to take enough to keep the stool soft. Remember to drink plenty of water during those days.

After Your Hemorrhoids Have Been Treated

After the procedure, you will have a little discomfort for several days. Expect some slight drainage and soreness in the rectal area for up to several weeks. However, you should be able to do most of your normal activities within a few days. If your doctor used the infrared coagulation, the direct current ablation or the electrocoagulation diathermy technique, you probably won’t have to take any time off from work. However, it would be best if you could take it easy for a couple of days after the procedure.

Here are some things you can do to make yourself more comfortable after the procedure, especially if skin tags were removed or if you have pain:

* Three to four times per day, soak in the bathtub for 20 to 30 minutes in warm (not hot) water.

* If your rectal area feels dry or irritated, you may apply witch hazel, Balneol cream or Anusol ointment. Nupercaine may soothe the pain.

* After you have a bowel movemnt, clean the rectal area with a moistened tissue, Tucks pad or a baby wipe.

* Until your rectal area is completely healed, use a stool bulking agent such as Metamucil, PerDiem Plain, Fibermed, Naturacil or Konsyl. Use one of these daily to keep your bowel movements soft.

* You may have some swelling and weeping of the tissues that have been treated. You can use a small sanitary pad to absorb the drainage. If the drainage is slightly tinged with blood, don’t worry. This is normal. You may have some bleeding for up to 14 days after treatment. Many times there won’t be any bleeding until the “scab” drops off, about 10 to 14 days after treatment. Don’t be concerned about a little blood unless you are passing clots.

* Call your doctor immediately if you have a fever or notice redness or swelling outside the rectal area. Call your doctor if you are unable to urinate.

* The swollen tissue on the inside of the rectum can make you feel as if you need to move your bowels, but you should avoid prolonged straining. Don’t use enemas for at least 14 days after the procedure. The enema tube could damage the tissue and cause bleeding.

* Take three ibuprofen tablets, 200 mg each, every six hours for pain. If you can’t take ibuprofen, take extra-strength acetaminophen (Tylenol).

* Make a follow-up appointment with your doctor for about four to five weeks from the day your procedure was performed.

This information provides a general overview on treatment of hemorrhoids and may not apply to everyone. Talk to your family doctor to find out if this information applies to you and to get more information on this subject.

COPYRIGHT 1995 American Academy of Family Physicians

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