Hemorrhoids are the most frequent anorectal disease. They appear when there is a dilation/thickening/prolapse/congestion/or bleeding of some structures like vascular “pads” that exist in the anal canal.
The following have been implicated in its appearance as predisposing factors:
- Bad defecation habits: prolonged effort, irregular intestinal rhythm, sitting for a long time…
- Low fiber diet.
- Diseases that affect the internal anal sphincter, anatomical alterations.
- Anal sphincter hypertonia.
Depending On The Anatomical Situation
- Internal hemorrhoids: located in the lower part of the rectum
- External hemorrhoids: they are located under the skin of the anus
Depending On The Degree Of Prolapse
- Grade I: there is no prolapse, they are only visible if an examination is performed (anoscopy).
- Grade II: they prolapse with defecatory effort but at the end they reduce spontaneously.
- Grade III: prolapse both spontaneous and with effort, protruding outside the anal canal and requiring manual reduction.
- Grade IV: the prolapse is persistent, not reducible, and may thrombose.
They appear in internal hemorrhoids, the external ones practically do not give symptoms. The higher the degree, the more important and numerous symptoms.
The most frequent are:
- Rectal bleeding: (rectal bleeding), is the most frequent symptom: it is red blood with defecation or when cleaning.
- Pain: generally appears when there is an associated complication such as an abscess, fissure, or in advanced degrees.
- Itching: is secondary to dermatitis that accompanies grade II-IV hemorrhoids due to mucous secretion.
- Prolapse: which is perceived as a foreign body sensation and incontinence (tenesmus).
- Other symptoms are a feeling of discomfort and discomfort, discharge, and small leaks (dirt).
Hemorrhoids can appear in the form of acute episodes, called hemorrhoidal crises, which consist of the exacerbation of symptoms.
What Are The Available Treatments?
There are several treatments available that are indicated depending on the symptoms and degree of hemorrhoids: dietary hygienic, instrumental (non-surgical), and surgical.
Diet Hygienic Treatment
includes diet and lifestyle changes. They are important to improve symptoms in mild cases and to prevent their recurrence. In the case of specific hemorrhoids and with mild symptoms, it is usually sufficient and effective:
- A diet rich in fiber together with adequate and abundant fluid intake: 1.5 to 2 liters a day.
- Physical exercise: a sedentary lifestyle favors constipation, which worsens hemorrhoids.
- Re-education of habits: avoid prolonged periods in the toilet, avoid sudden efforts during defecation, and try to establish a fixed daily time to go to the bathroom.
- Topical treatment:sitz baths in warm water (a duration of about 10 minutes is recommended, every 4-6 hours and after bowel movements).
- The creams reduce symptoms in acute cases (inflammation) and should only be used for a few days as continued use can be counterproductive.
The most symptomatic hemorrhoids may require other treatments.
Instrumental Treatment (Non-Surgical)
- Elastic (band) ligation: A band is placed at the base of hemorrhoid that cuts off circulation, causing the hemorrhoid to dislodge. It is usually done without anesthesia and on an outpatient basis. Sometimes it may require several sessions.
- Sclerosis: by injecting a chemical substance at the base of the hemorrhoid, the blood supply is interrupted.
Hemorrhoid surgery is indicated in around 5%-10% of patients.
The criteria for its indication include very symptomatic hemorrhoids in which the aforementioned previous treatments have already been tried, in grades III or IV with therapeutic failure, and when they are associated with other problems such as anal fissure or fistula.
What Kind Of Surgeries Are There?
The surgery requires no special preparation (not even enema cleaning or shaving).
It consists of the resection of the hemorrhoidal tissue together with the rectal mucosa, leaving the skin and anal mucosa intact to prevent stenosis or fissures. The internal anal sphincter is identified and preserved. It is usually performed with local anesthesia associated with sedation. The use of a surgical anoscope is convenient.
Hemorrhoidectomy With Harmonic Scalpel And With Vessel Sealant
It has a shorter duration. It seems that it causes less discomfort than conventional surgery and that the bleeding is less.
It has not shown any advantage over conventional surgery.
Hemorrhoidopexy Or Mechanical Circular Anopexy
A resection of a band of rectal mucosa above the hemorrhoids is performed using a stapler called a PPH. The hemorrhoids are not removed but are placed in their original position, which improves venous flow, preserves continence, does not cause stenosis and the postoperative period is more comfortable.
Doppler-guided hemorrhoidal artery ligation. It requires a special anoscopy. They are recommended in grades II and III of prolapse.
What Are The Complications?
As in any surgical intervention, there are a series of complications. They are divided according to severity and frequency into:
- Not very serious and frequent: Infection or bleeding from the wound, acute retention of urine, inflammation (edema) of the anus, prolonged pain in the area of the operation.
- Uncommon and more serious: Significant infection of the anus and perineum. Incontinence (gas and even feces), narrowing (stenosis) of the anus, and reappearance of hemorrhoids.
The complication rate after hemorrhoid surgery is considered to be low, around 1-2%. These are clearly related to the technique, the degree of experience, and postoperative care.
It is contraindicated in the presence of another active colorectal disease (inflammatory bowel disease), severe immunodeficiency, and/or fecal incontinence.
What Is The Postoperative Care?
- Oral analgesia should be started 6-12 hours after the intervention. Anxiolytics and muscle relaxants can be associated. In the first hours, they can be administered subcutaneously or intramuscularly.
- Sitz baths with warm water are recommended. No dressings are required (they stick and are painful to remove).
- Early defecation of feces with little effort should be encouraged by fiber or lactulose supplements.
- Review with the specialist.
What you should know…
- Constipation, bad defecation habits, pregnancy, low fiber diet, and age… are some of the factors that can predispose to hemorrhoids.
- There are several treatments available that are indicated depending on the symptoms and degree of hemorrhoids.
- When dietary hygienic treatment does not work and it is very symptomatic hemorrhoids, instrumental treatment (non-surgical) or surgical treatment (surgery) can be used.