Effectiveness of different hemorrhoids treatment methods

What is Hemorrhoids?
Types and classification
Treatment options: efficacy, risks & complications
Contraindications for fixative or surgical procedures

What is Hemorrhoids?

Hemorrhoids are swollen blood vessels in and around the anus and lower rectum. They stretch under pressure and are similar to varicose veins in the legs.

About half the U.S. population has experienced hemorrhoids by age 50. Men are more frequently afflicted than women, and the peak incidence of the disease occurs between the ages of 45 and 65. Hemorrhoids are common among pregnant women. The process of childbirth also puts severe stress of these vessels. People whose parents had hemorrhoids may be more likely to get them. Being very overweight, or standing or lifting too much can make hemorrhoids worse.

Types and classification

Hemorrhoids are categorized as either internal or external hemorrhoids.

Internal hemorrhoids involve the veins inside your rectum. Internal hemorrhoids usually don't hurt but they may bleed painlessly. Sometimes, an internal hemorrhoid may stretch down until it bulges outside your anus. This is called a prolapsed hemorrhoid. A prolapsed hemorrhoid will go back inside your rectum on its own, or you can gently push it back inside. If internal hemorrhoids protrude from the anal opening and cannot be pushed back, they can cause severe pain.

Internal hemorrhoids are classified by degree of severity according to the extent of prolapse:

First degree: hemorrhoid does not prolapse from the anus.
Second degree: hemorrhoid prolapse from the anus during a bowel movement but returns to the anal canal afterward.
Third degree: hemorrhoid prolapse from the anus during a bowel movement, but can be pushed inside the anus with manual reduction
Fourth degree: hemorrhoid is always outside the anus and cannot be pushed into the anal canal (incarcerated, irreducible prolapse)

External hemorrhoids involve the veins outside the anus. External hemorrhoids are often fairly painful, because the skin around them is very sensitive. If a blood clot forms (creating what is called a thrombosed hemorrhoid), you may feel a tender lump on the edge of your anus. A thrombosed hemorrhoid will not cause an embolism. External hemorrhoids bleed when broken by straining, rubbing, or scratching. Small external hemorrhoids usually do not produce symptoms.

Treatment options

The choice of treatment depends on the size of the hemorrhoids. Hemorrhoids are treated with home treatment, fixative (nonsurgical) procedures, and surgery.

The goal of fixative procedures is to reduce the blood supply to the hemorrhoid, causing the hemorrhoid to shrink or wither away. These nonsurgical treatments cure most smaller and some larger internal hemorrhoids. Fixative procedures include rubber band ligation; injection sclerotherapy; and coagulation therapy with devices that use heat, a laser, or an electrical current. These are called fixative procedures because the scar that results keeps nearby veins from bulging into the anal canal.

Surgical removal of hemorrhoids (hemorrhoidectomy) is the most successful way to treat large internal hemorrhoids. Small internal hemorrhoids are sometimes treated surgically when several hemorrhoids are present, bleeding cannot be controlled with other treatments, or both internal and external hemorrhoids are present.

Some treatments are more effective but at the same time are more painful, others are less painful but their efficacy is also lower. Side effects and recurrence vary with the procedure. Thus, comfort or efficacy is a major concern.

Relative contraindications for the nonsurgical treatment of internal hemorrhoids include the presence of inflammatory bowel disease, rectal prolapse, infectious processes, immunodeficiency disorders, coagulopathy, and pregnancy or the immediate postpartum state.

Rubber band ligation (RBL)

The most commonly used hemorrhoid procedure in the United States is rubber band ligation. Rubber band ligation technique was originally described by Barron in 1963. RBL is a procedure in which the hemorrhoid is tied off at its base with rubber bands, cutting off the blood flow to the hemorrhoid. A scar will form in place of the hemorrhoid, holding nearby veins so they don't bulge into the anal canal. Treatment is limited to 1 to 2 hemorrhoids at a time if done in the doctor's office. Several hemorrhoids may be treated at once if the person has general anesthesia. Additional areas may be treated at 4- to 6-week intervals.

Because this treatment can be painful, some people might not choose it. Although a different treatment might be less painful, it may not be as effective, and it may need to be repeated to treat recurring hemorrhoids.

Indications:
Rubber band ligation is the most widely used treatment for second- and third-degree hemorrhoids. Rubber band ligation cannot be used with first-degree hemorrhoids, since there is not enough tissue to pull into the banding device. This procedure is can be applied successfully in selected cases with fourth degree hemorrhoids, but with an increased rate of recurrence [4].

Efficacy:
Rubber band ligation is used to treat hemorrhoids that are too large to be treated by injection sclerotherapy and infrared photocoagulation. Most experts believe rubber band ligation is the most effective nonsurgical treatment for internal hemorrhoids. The success rate of this method is more than 80% [1], [2]. If the symptoms return after rubber band ligation, they can be treated again with rubber band ligation or other treatments. Improvements in symptoms after rubber band ligation appear to last longer than after other types of fixative procedures.

Rubber band ligation provides more rapid and longer-lasting relief than injection sclerotherapy or infrared photocoagulation therapy.
Repeat treatment for recurring symptoms is rarely needed.
This procedure is most useful for small- to medium-sized internal hemorrhoids [2].
The procedure is less likely to be successful for large hemorrhoids.
Rubber band ligation is one of the least expensive treatments and also one of the most effective.

Risks and possible complications:

Severe pain, especially during bowel movements, that does not respond to the methods of pain relief used after this procedure [3]. The bands may be too close to the area in the anal canal that contains pain sensors.
Bleeding from the anus.
Thrombosed external hemorrhoids [1].
Inability to pass urine (urinary retention) [5].
Infection in the anal area [5]. Necrotizing pelvic sepsis is a rare, but serious, complication of rubber band ligation.

Injection sclerotherapy

Injection sclerotherapy is a medical procedure used to treat small internal hemorrhoids. This fixative procedure uses a chemical that is irritating to tissues to cut off the hemorrhoids' blood supply. The doctor injects the chemical into the vein within a hemorrhoid. The chemical causes the vein to harden and the hemorrhoid tissue to die. A scar forms in place of the hemorrhoid on the wall of the anal canal. Injection sclerotherapy is done less often than other fixative procedures. The success of injection sclerotherapy depends largely on the doctor's expertise.

Indications:
Traditionally, injections are indicated for first-degree and second-degree hemorrhoids but not for use with external hemorrhoids. Injection sclerotherapy is used in cases where internal hemorrhoids are too small to treat with rubber band ligation. It is used if you have persistent bleeding from hemorrhoids, if you are older than age 70, or if you are in poor health and would not be a candidate for more invasive surgery.

Efficacy:
For small hemorrhoids, injection sclerotherapy relieves symptoms about as well as rubber band ligation. However, sclerotherapy does not work as well as ligation for large hemorrhoids. Hemorrhoids often recur after injection sclerotherapy. Treatments can be repeated. Injection sclerotherapy may be an effective short term treatment for bleeding first and early second-degree haemorrhoids. However, many patients will require further treatment. Multiple injections have not been shown to confer any benefit. Its disadvantage is the high failure rate, and the apparent need for further treatment. Sclerotherapy may be not suitable for anterior haemorrhoids [6].

Risks and possible complications:
Complications of sclerotherapy are rare, but usually result from an injection placed too deeply, especially anteriorly in the male.

Rare complications include:

Painful burning if the injection is given too close to the anus, where pain-sensitive nerve endings are located
Allergic reaction to the injected chemical
Shedding of the rectal lining (mucosa), leaving an open wound
Urinary retention
Epididymoorchitis
Infection of the anal area
Infection of the prostate gland (prostatitis) in men
Bleeding
Impotence, rare but serious complication [8]

Infrared photocoagulation

Infrared coagulation techniques for the thermal ablation of haemorrhoids were first described by Neiger in 1977. Infrared photocoagulation (also called coagulation therapy) is a medical procedure used to treat small- and medium-sized hemorrhoids. During the procedure, the doctor uses a device that creates an intense beam of infrared light. The light creates scar tissue, cutting off the blood supply to the hemorrhoid. The hemorrhoid dies, and a scar forms on the wall of the anal canal. The scar tissue holds nearby veins in place so they don't bulge into the anal canal. Only one hemorrhoid can be treated at a time. Other hemorrhoids may be treated at 10- to 14-day intervals.

It has fewer risks than injection sclerotherapy and a similar success rate. It is generally more expensive than injection sclerotherapy.

Results for nonprolapsing hemorrhoids appear to show that this is a superior technique to injection sclerotherapy. It is less technique dependent and avoids the potential complications of misplaced injections. Although larger, prolapsing haemorrhoids may not respond as well to this technique, photocoagulation provides a safe, rapid and non-invasive alternative to other outpatient procedures. Its use may be limited by the availability and expense of the equipment.

Indications:
Infrared coagulation is the most widely used treatment for small internal hemorrhoids that continue to cause symptoms after home treatment. It is useful for first-degree and second-degree hemorrhoids. Infrared coagulation is not effective in treating large amounts or prolapsing tissue. IRC is also preferred procedure if you are older than age 70 or are in poor health and would not be a candidate for more invasive surgery.

Efficacy:
Small internal hemorrhoids are often successfully treated with coagulation therapy. Large hemorrhoids are more likely to be treated with rubber band ligation [7].

Risks and possible complications:
Infrared photocoagulation causes fewer and less serious complications than rubber band ligation and injection sclerotherapy. Possible comlications include:

Pain during and after procedure [7].
Bleeding from the anus [7].
Infection in the anal area.
Temporary inability to urinate.

Hemorrhoidectomy

Hemorrhoids infrequently require operative intervention. Surgery to remove hemorrhoids is called hemorrhoidectomy. With the growing popularity of newer, non-surgical treatment methods, the number of hemorrhoidectomies has declined dramatically. Surgery may provide better long-term results than fixative procedures. However, surgery is more expensive and more painful, requires a longer recovery time, and has a greater risk of complications.

During hemorrhoidectomy, the doctor makes incisions around the anus to cut away the hemorrhoids You may need surgery if you have large protruding hemorrhoids, persistently symptomatic external hemorrhoids, or internal hemorrhoids that return despite rubber band ligation. The procedure doesn’t involve an overnight hospital stay, but it does require general anesthesia, and most patients need narcotic analgesics afterward. Patients can usually return to work after 7-10 days.

Indications:
Hemorrhoidectomy is appropriate in the following cases:

Failure of medical therapy and nonoperative techniques
Symptomatic third-degree haemorrhoids not responding to banding and fourth-degree haemorrhoids
Mixed internal and external hemorrhoids
Symptomatic hemorrhoids in the presence of a concomitant anorectal condition that requires surgery
Patient preference, after discussion of treatment options with the referring physician and surgeon.

Surgery is rarely done to treat hemorrhoids during pregnancy unless you have a clotted (thrombosed) external hemorrhoid. However, it can be done if pain and bleeding persist after nonsurgical treatment.

Efficacy:
Hemorrhoidectomy is the most effective treatment for hemorrhoids. Surgery usually cures a hemorrhoid. Hemorrhoids recur 5% to 8% of the time after hemorrhoidectomy.

Risks and possible complications:
Most common side effects and complications associated with hemorrhoidectomy:

Pain, which may last for weeks
Bleeding
Inability to urinate (pain following surgery makes it difficult to relax and allow urine to flow)
Fecal incontinence (the inability to control your bowels, which can lead to the involuntary release of feces or gas)
Infection of the surgical area
Reaction to anesthesia

In rare cases, a more serious complications may develop weeks after surgery, such as:

Stenosis (narrowing) of the anal canal
Fistula formation (abnormal openings in the area around the anus)
Nonhealing wounds
Abscesses (pockets of infection near the anus)
Rectal prolapse (occurs when the mucous membrane lining the rectum slips out of the anal opening)

Contraindications for fixative or surgical procedures

People who have certain health conditions may not be able to have some fixative or surgical procedures. These include:

Bleeding disorders or taking medication to prevent blood clots (blood thinners or anticoagulants).
Rectal prolapse.
Anal tumors or narrowing (strictures) at the opening of the anal canal.
A large tear in the lining of the anal canal (anal fissure) or infection around the anus.
Crohn's disease or ulcerative colitis.
Cirrhosis of the liver.
Irritable bowel syndrome or other conditions that cause a person to have frequent diarrhea, severe constipation, or both.
Heart failure.
Portal hypertension.

More information about Hemorrhoids:

References:

1. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum. 2004 Aug;47(8):1364-70. PubMed
2. Pe'rez Vicente F, Ferna'ndez Fri'as A, Arroyo Sebastia'n A, Serrano Paz P, Costa Navarro D, Candela Polo F, Ferrer Riquelme R, Oliver Garci'a I, Lacueva Go'mez FJ, Calpena Rico R. Effectiveness of rubber band ligation in haemorrhoids and factors related to relapse. Rev Esp Enferm Dig. 2003 Feb;95(2):110-4, 105-9. PubMed
3. Kumar N, Paulvannan S, Billings PJ. Rubber band ligation of haemorrhoids in the out-patient clinic. Ann R Coll Surg Engl. 2002 May;84(3):172-4. PubMed
4. Komborozos VA, Skrekas GJ, Pissiotis CA. Rubber band ligation of symptomatic internal hemorrhoids: results of 500 cases. Dig Surg. 2000;17(1):71-6. PubMed
5. Bat L, Melzer E, Koler M, Dreznick Z, Shemesh E. Complications of rubber band ligation of symptomatic internal hemorrhoids. Dis Colon Rectum. 1993 Mar;36(3):287-90. PubMed
6. Al-Ghnaniem R, Leather AJ, Rennie JA. Survey of methods of treatment of haemorrhoids and complications of injection sclerotherapy. Ann R Coll Surg Engl. 2001 Sep;83(5):325-8. PubMed
7. Linares Santiago E, Go'mez Parra M, Mendoza Olivares FJ, Pellicer Bautista FJ, Herreri'as Gutie'rrez JM. Effectiveness of hemorrhoidal treatment by rubber band ligation and infrared photocoagulation. Rev Esp Enferm Dig. 2001 Apr;93(4):238-47. PubMed
8. Pilkington SA, Bateman AC, Wombwell S, Miller R. Anatomical basis for impotence following haemorrhoid sclerotherapy. Ann R Coll Surg Engl. 2000 Sep;82(5):303-6. PubMed

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