Commonly known among the public as “piles” or “anal itching,” hemorrhoidal disease arises from the enlargement and displacement of vascular cushions in the lower part of the anal canal. This condition typically presents with symptoms such as pain, bleeding, itching, discharge, and palpable lumps in the anal region. It significantly affects patients’ quality of life and work performance. Therefore, its diagnosis and treatment should be addressed in light of the current medical literature.
Classification of Hemorrhoidal Disease
Hemorrhoids are classified into two groups based on their anatomical location: internal and external. Internal hemorrhoids are located above the dentate line, while external hemorrhoids are below it. Internal hemorrhoids are further categorized by degree:
- Grade 1: Bleeding may occur, but there is no prolapse.
- Grade 2: Prolapse occurs with defecation but retracts spontaneously.
- Grade 3: Prolapse occurs and requires manual reduction.
- Grade 4: Permanently prolapsed and cannot be manually reduced, often accompanied by complications.
Diagnostic Approach
Diagnosis begins with a detailed medical history. We inquire about symptoms such as rectal bleeding, changes in bowel habits, pain, and itching. This is followed by a physical examination and anoscopy. In some cases, advanced imaging techniques like colonoscopy may be required, especially for patients over the age of 50 or those presenting with bleeding, to rule out serious conditions such as colorectal cancer.
Treatment Approaches
Treatment is individualized based on the disease stage, symptoms, and the patient’s general health status. Today, both medical and surgical treatment options are available, with initial preference given to conservative management.
Medical (Conservative) Treatment:
First-line treatment for Grade 1 and 2 hemorrhoids includes lifestyle modifications and medications, such as:- Dietary adjustments: High-fiber diet, adequate fluid intake, promoting regular bowel movements, and avoiding spicy foods.
- Improved toilet habits: Establishing routine bowel movements, avoiding prolonged straining, and refraining from using mobile phones or reading while on the toilet.
- Medications: Topical corticosteroid creams, anesthetic ointments, and orally administered venotonic agents.
- Warm Sitz baths: Applied 2–3 times daily for 10–15 minutes.
These treatments often alleviate symptoms effectively. However, in recurrent or advanced cases, more invasive interventions may be necessary.
- Minimally Invasive Procedures:
These are preferred in cases unresponsive to medical treatment or in Grade 2 and 3 hemorrhoids. They are painless and offer rapid recovery:- Rubber Band Ligation: A rubber band is applied at the base of the internal hemorrhoid to cut off circulation. The tissue necroses within 7–10 days, resulting in resolution.
- Sclerotherapy: A sclerosing agent is injected into the hemorrhoidal tissue, causing the vessels to collapse and shrink. It is especially advantageous in elderly patients or those on anticoagulants.
- Laser Ablation, Infrared Coagulation, and Bipolar Diathermy: These methods use thermal energy to coagulate hemorrhoidal vessels. They are simple and painless, effective especially for Grades 1 and 2, and to some extent Grade 3.
Laser therapy, in particular, has become increasingly popular in recent years due to its low complication and pain rates.
- Surgical Treatment Methods:
Surgery is typically recommended for Grade 3 and 4 hemorrhoids, thrombosed external hemorrhoids, or cases resistant to other treatments. Modern surgical methods include:- Conventional Hemorrhoidectomy (Milligan-Morgan, Ferguson, etc.): These are radical treatments involving the complete removal of hemorrhoidal tissues in accordance with the three-sector rule. Although associated with longer recovery and more pain, recurrence rates are low. However, there is a higher risk of complications.
- Stapled Hemorrhoidopexy (Longo Procedure): This method involves lifting the internal hemorrhoids upward without tissue removal, aiming to reduce blood flow and prolapse. It causes less pain but may result in specific complications (e.g., stenosis), thus is mainly reserved for advanced cases with prolapse.
- THD (Transanal Hemorrhoidal Dearterialization): An increasingly used method where hemorrhoidal arteries are located and ligated under Doppler ultrasound guidance. This reduces blood flow, leading to hemorrhoid shrinkage. It is a minimally invasive technique with minimal pain.
Postoperative Period and Follow-Up
As with all surgical interventions, hemorrhoid surgery requires careful postoperative monitoring. Regular follow-up appointments are essential. In the first few weeks, attention should be paid to:
- Keeping the surgical site clean
- Pain control with analgesic treatment
- Adherence to a high-fiber diet and adequate fluid intake
- Use of stool softeners if needed
- Making lifestyle changes permanent to prevent recurrence
