Hemorrhoidal Disease: How to Proceed After Unsuccessful Medical Treatment?

Abstract

Hemorrhoids are the symptomatic enlargement and displacement of the normal anal vascular plexus. It is estimated that up to 50% of the adult population may eventually develop hemorrhoids. The incidence increases with age and is more common in males than females. Hemorrhoidal disease has a multifactorial etiology, but it mainly results from increased pressure on the hemorrhoidal veins, leading to vascular congestion, enlargement, and subsequent protrusion. The condition is characterized by swelling and inflammation of the blood vessels in the anal canal. Hemorrhoids are classified into two types: internal hemorrhoids, which occur inside the anal canal, and external hemorrhoids, which occur outside the anus. Clinical presentation includes rectal bleeding, prolapse sensation, anal pain, irritation, and/or anal discharge. The most common symptom is rectal bleeding, which is usually painless and associated with defecation. The patient's history and clinical examination establish the diagnosis of hemorrhoids. Treatment depends mainly on the severity of the condition. Conservative therapies such as dietary modifications, increased fiber intake, and sitz baths may be sufficient for mild cases. Topical medications such as corticosteroids, vasoconstrictors, and local anesthetics may also relieve symptoms. Minimally invasive procedures such as rubber band ligation, sclerotherapy, cryotherapy, or infrared coagulation may be recommended for more severe cases. For those severe cases that do not respond to other treatments, a more invasive procedure (hemorrhoidectomy) may be necessary. This article provides a comprehensive overview of the different therapeutic alternatives for hemorrhoids, mainly focusing on surgical procedures.