RISK FACTORS: Pregnancy, Colon malignancy, Liver disease, Portal hypertension, Constipation, Occupations that require prolonged sitting, Loss of muscle tone in old age, rectal surgery, episiotomy,,anal intercourse, Obesity, Chr diarrhea
APPROPRIATE HEALTH CARE
All of these treatments, except surgical, are outpatient with recovery and freedom from symptoms within 48
hours
GENERAL MEASURES
o Hemorrhoids are a recurrent disease, even after surgical excision; measures for prevention should be taken
o Mild symptoms or prevention:
? Avoid prolonged sitting at stool
? Avoid straining
? Avoid constipation through stool softeners, and high fiber intake in diet or with supplements
? Use soap and water for cleanup after stool
o For pain, sitz baths with soapy water, or hypertonic epsom salts (cup per 2 quarts of water)
o Mild and minimal hemorrhoids respond to changed diet, relief of constipation, soap and water cleanup and brief stooling
o Pruritus or mild discomfort after stooling responds to hydrocortisone ointment, anesthetic ointments or sprays
o Mild bleeding with external hemorrhoids responds to sitz baths and ointments or suppositories
o Hemorrhoids often progress from itching bleeding stage, to protrusion with easy reduction, then difficult
reduction, and fi nally rectal prolapse. Thrombosis may occur at any protrusion stage. Constipation relief, anal hygiene, local ointments, and soaks are effective through the stage of easy reduction, but the more severe stages require rubber band ligation or rectal surgery.
SURGICAL MEASURES
o Indications
? Persisting and soiling bleeding
? Prolapsed internal hemorrhoids
? Poor anal hygiene due to prolapsed hemorrhoids
? Persistent pain
o Treatments
? For severe pain:
- Incision of thrombosed hemorrhoid
? Severe protruding hemorrhoids:
- Rubber band ligation (internal hemorrhoids only)
- Injection therapy (suitable for one or two)
- Cryosurgery, infrared or laser surgery for external hemorrhoids
? Prolapsed rectum
- Requires surgical correction
? Surgical resection - for major external or internal hemorrhoids
ACTIVITY
o No restrictions
o Encourage physical fitness
o Avoid prolonged sitting and straining on the toilet
DIET High fiber
PATIENT EDUCATION Explain recurrence benignity, need for good diet, exercise and stooling health
DRUG(S) OF CHOICE
o Prevention:
? Fiber supplements
? Stool softeners
o Pain:
? Analgesic sprays or ointments - benzocaine, dibucaine (Nupercainal). Use sprays with caution as they may contain alcohol that can cause burning sensation when applied.
o Pruritus:
? Hydrocortisone (Anusol-HC, Cortifoam) ointment
o Bleeding:
? Astringent suppositories (Preparation H)
? Hydrocortisone (Anusol; Cortifoam) ointment
PATIENT MONITORING As needed, depending on treatment
PREVENTION/AVOIDANCE
o Avoid constipation
o Lose weight, if overweight
o Avoid prolonged sitting on the toilet
o Avoid prolonged sitting at work. Get up and move around periodically.
POSSIBLE COMPLICATIONS
o Thrombosis
o Secondary infection
o Ulceration
o Anemia (rare)
o Incontinence
EXPECTED COURSE/PROGNOSIS
o Spontaneous resolution
o Recurrence