How Are Hemorrhoids Treated?

Hemorrhoids usually have a tendency to keep reoccurring, therefore most people feel that it is usually best to treat them as little as possible. In many cases, the problem usually disappears on its own, in a few days, even without any treatment. However this may not always be the case and if you have been suffering from piles for a long time then you know that it can be quite a nuisance. In this chapter we deal with some of the treatments available for hemorrhoids. These range from simple medications and over-the-counter creams to non-surgical and surgical procedures for dealing with piles.

Medications
If your hemorrhoids are not too troublesome or if the symptoms are very mild, then usually the first line of treatment for hemorrhoids are simple medications such as over-the-counter creams, or gels or suppositories. All these medications are aimed at relieving itching and pain by reducing the swelling and bleeding from the piles. Some patients also find relief by applying cold compresses to the affected area. Even daily warm baths can help you deal with the pain and discomfort. If the medication is only a topical cream, then it may be applied with your finger. At times the medicines may need to be inserted inside the anal canal for which there are instruments such as pile pipes, which have holes on the sides that dispense the medication inside your rectum.

Some of the most simple treatment for piles are:

Stool softeners. Since straining and constipation are the biggest factors in causing piles, these medicines such as Colace (Docusate sodium) act by increasing the absorption of water and fat into the stool, which makes it soft. The soft stool is easy to pass and this reduces the excess pressure on the hemorrhoids.

Topical Anesthetics -- such as Benzocaine and Lidocaine act by numbing the nerve endings and provide temporary relief from pain and itching. The anesthetics are usually applied locally at the site of the pain and should be used sparingly as their excess use can cause some allergic reactions. Some common local anesthetics
Benzocaine 5% to 20% (Americaine Hemorrhoidal, Lanacane Maximum Strength, Medicone)
1. Benzyl alcohol 5% to 20%
2. Dibucaine 0.25% to 1.0% (Nupercainal)
3. Dyclonine 0.5% to 1.0%
4. Lidocaine 2% to 5%
5. Pramoxine 1.0% (Fleet Pain-Relief, Procto Foam Non-steroid, Tronothane Hydrochloride)
6. Tetracaine 0.5% to 5.0%

Astringents –Astringents are applied around the anus after passing stool. The astringent causes the cells of the skin to clump thereby drying the skin, which gives relief from burning and itching. Some common astringents include:

1. Hamamelis water (Witch Hazel) -- Mild astringent prepared from twigs of Hamamelis virginiana, used to temporarily relieve itching of hemorrhoids.
2. Calamine 5% to 25%
3. Zinc oxide 5% to 25% (Calmol 4, Nupercainal, Tronolane)

Analgesics such as Tylenol, Aspirin, Anacin and Feveral help in reducing pains –especially in those patients who have very painful lesions.

Vasoconstrictors – Since a common cause of hemorrhoids are swollen blood vessels, chemicals such as vasoconstrictors also help in relieving symptoms of piles. This category of medicines mimics the action of epinephrine, a naturally occurring chemical. On application around the anus, vasoconstrictors cause the blood vessels to shrink, which reduces swelling. These products also contain some mild form of anesthetic, which helps in reducing pain and itching. Since these are only applied locally these products do not usually cause any problems. In very few cases, there may be side effects such as high blood pressure, sleep loss, tremors and so on.

The most commonly used Vasoconstrictors include:
1. Ephedrine sulfate 0.1% to 1.25%
2. Epinephrine 0.005% to 0.01%
3. Phenylephrine 0.25% (Medicone Suppository, Preparation H,

Rectacaine)

Protectants – One of the biggest complications of hemorrhoids occurs when the hard stool, during a motion, tears the skin around the anal area. When this tender skin comes in contact with liquid or stool again it causes the skin to itch and burn. When Protectants are applied to the anal area, they form a physical barrier on the skin. This reduces the pain and itchiness as well as prevents the broken skin from coming in contact with offending particles in the stool. There are many kinds of protectants, some of the more common ones being:

1. Aluminum hydroxide gel
2. Cocoa butter
3. Glycerin
4. Kaolin
5. Lanolin
6. Mineral oil (Balneol)
7. White petrolatum
8. Starch
9. Zinc oxide or calamine (which contains zinc oxide) in

concentrations of up to 25%
10. Cod liver oil or shark liver oil if the amount of vitamin A is 10,000 USP units/day.

Antiseptics – If the skin around the anal area gets bruised during motion it can get affected with bacteria and other organisms. To keep the area clean and to prevent infection, sometimes patients are advised the use of antiseptics. However even keeping the area clean with soap and water might also serve the same purpose.
Examples of antiseptics include:
1. Boric acid
2. Hydrastis
3. Phenol
4. Benzalkonium chloride
5. Cetylpyridinium chloride
6. Benzethonium chloride
7. Resorcinol

Keratolytics – Then there are chemicals such as Keratolytics that cause the outer layers of skin or other tissues to disintegrate. This makes it easier for the pile medication to penetrate deeper into the tissues, thereby bringing quick relief.

The two approved keratolytics used are:
1. Aluminum chlorhydroxy allantoinate (alcloxa) 0.2% to 2.0%
2. Resorcinol 1% to 3%

Non-surgical procedures
Usually it is easy to treat hemorrhoids with simple creams and medicines as discussed previously. But sometimes if the pain is difficult to bear or the symptoms persistent for long, doctors may advise a procedure to remove the piles. The procedures discussed in this section are non-surgical; they do not require admission to the hospital and many times can be done without any anesthesia. All these methods work on cutting off the blood supply to the piles, which cause them to shrink and fall. As the piles fall, it creates a scar or ulcer at the site. When the scars heal it causes the tissues of the anal canal to shrink and attach to the underlying muscle of the anal canal. Once the tissues have been attached to the muscle, it does not get pulled down from its position. These procedures are also more useful for patients who have Grade 1, 2 or 3 of piles Banding

Banding as the word suggests, literally implies placing an elastic band at the base of the pile. This elastic band then cuts off the blood supply to the pile causing it to shrink and drop off on its own. The fallen off pile gets sent out of the body with a motion. The bands too fall off after some time.

Banding is most effective for treating those piles that protrude during defecation. It is commonly used for treating second and third degree piles. Sometimes if the problems with first degree piles exist and all self help methods have failed, then banding is recommended for treating those piles as well. This procedure can be used to treat up to three piles at a time and can be repeated if all piles do not clear off the first time.

Although it is a safe procedure, banding does cause some mild discomfort and pain. At times there may be bleeding also. Care must be taken to avoid spread of bacterial infection in the surrounding tissues, and to prevent the infection from spreading into the bloodstream or to the pelvis. People who suffer from immune disorder such as AIDS, Cancer, or severe diabetes need to take very good care if they go in for banding.

Sclerotherapy

Under this form of treatment, a chemical known as a sclerosant (which usually has phenol in it) is injected into the piles, which causes them to shrink. Since the solution usually contains nut oil, patients who are allergic to nuts should not use it. The treatment may have to be repeated once or twice. There is mild pain with the treatment but it subsides soon.

Cryosurgery
Under Cryosurgery, the piles are frozen which causes them to shrink and fall off. This is not a very effective treatment for piles, since it causes more post treatment pain. It is also less effective than banding and therefore is rarely used.

Heat coagulation

A more effective treatment is to use heat to kill tissues in and around hemorrhoids and promote inflammation and scarring. The heat is produced using direct-current electrotherapy or infrared photocoagulation. Heat coagulation is useful for treating first, second or third degree hemorrhoids. Although there is pain and bleeding associated with the procedure, it is less than ligation or other procedures.

Light coagulation

Ligation and Sclerotherapy work best with those piles that stick out of the body, whereas Light Coagulation is an effective treatment for piles that do not protrude out of the body ((non-prolapsing piles). A 1- or 2-second burst of infrared light is passed over the piles that cus off circulation to small, bleeding, internal hemorrhoids causing them to shrink and drop off.

Sclerotherapy, ligation, and heat coagulation are all good options for the treatment of hemorrhoids.

Surgical treatments
Hemorrhoid surgery is only recommended if the other treatments – such as medicines or non-surgical procedures – haven’t been successful in treating hemorrhoids. Surgery is also done if the hemorrhoids are too large or cause a lot of discomfort. In fact studies have shown that about 90 percent cases of hemorrhoids get better without a surgery, if the patients begin treatment on time. It is always better to exhaust all non-surgical treatments first because they cause less pain and fewer complications than surgical interventions. Typically under a surgical procedure, the doctors remove the offending tissue in a procedure called hemorrhoidectomy.

Hemorrhoidectomy

This procedure is usually reserved for very severe cases of piles, like fourth degree internal piles or when clots repeatedly form in external hemorrhoids. It is usually done after other procedures like ligation treatment, has failed to reduce protruding hemorrhoids or if bleeding from hemorrhoids gets very severe. Then a surgery might be performed to cut out the hemorrhoids – both internal as well as external.

There are several ways in which a hemorrhoidectomy can be performed. First the surgeon places a tight stitch around the base of the pile. This is done to make sure that there is not too much bleeding during the operation. After that the surgeon removes excess tissue from the outer part of the pile. When this is done the surgeon closes the wound with dissolvable stitches most of which are inside the body. These stitches go away by themselves and do not need to be taken out.

The doctor will administer an anesthetic – either a local anesthetic combined with sedation, or a spinal anesthetic, or general anesthetic before the surgery. This may at the most require one day’s stay at the hospital, in many cases this is done as an outpatient procedure. You may be under some pain after the surgery for which the doctor will prescribe strong painkillers. Sometimes the doctor may even ask you to soak in a warm bath to reduce the pain.

It is very rare to have complications after this surgery. But there are some patients (5 percent) who complain of temporary difficulty in passing urine. In very rare cases there may be heavy bleeding a few days after surgery, or a narrowing of the anal passage due to scarring of the tissues in that area.

Stapled Hemorrhoidectomy

In the mid 1990s a new surgical procedure for treating hemorrhoids came up in Europe. It was considered as a better alternative to a normal hemorrhoidectomy since it required a much shorter stay in the hospital, lesser pain and the patient could resume his normal routine much sooner. The technique is called a stapled hemorrhoidectomy. Under this procedure the surgeon places a circular stapler inside the patient’s rectum. This stapler then removes some rectal tissue above the hemorrhoids, which cuts off the blood supply to the piles so they reduce in size. As the cut tissue heals, the hemorrhoids return to their normal position inside the anal canal. After a few weeks the staples just fall off with the stool. The procedure takes less than an hour and is preferred over a conventional hemorrhoidectomy since it does not involve removing the hemorrhoids, only the abnormal tissue surrounding it.

A stapled hemmorhoidectomy is usually done for treating internal hemorrhoids, but if a patient has external hemorrhoids as well then it can also reduce those. Although it is considered a safe procedure, like with any surgery there are some risks involved with a stapled hemorrhoidectomy too. The surgeon must have the skill to place the staples inside the rectum and it is always safer to go to a doctor who has done several such procedures. It is also a more expensive procedure than a conventional hemorrhoidectomy.

There is some postoperative disomfort, such as bleeding, infection, and narrowing of the anal canal. Some patients feel fullness in their rectum for several days after the procedure. As with all procedures, the hemorrhoids may recur even after the surgery. But despite that a stapled hemorrhoidectomy is becoming a popular procedure for treating piles the world over.

Doppler ligation

The hemorrhoidal tissues are rich in blood supply. With the help of a a special, illuminated anoscope, with a Doppler probe that measures blood flow, doctors have been able to identify the individual artery that supplies blood to the the hemorrhoidal vessels. If this artery is tied up (a process known as ligation) then it causes the hemorrhoids to shrink. This procedure is called the Doppler Ligation. It is an expensive procedure and therefore not used very frequently.