What procedures can be done?

Photo of a hospital visit (PantherMedia / Robert Kneschke) Sometimes the symptoms of enlarged hemorrhoids are so bad that treating the symptoms alone is no longer enough. Then there are various procedures that can be done to remove the tissue that is causing problems.

Hemorrhoids are normal “cushions” of tissue filled with blood vessels, found at the end of the rectum, just inside the anus. If they become enlarged, they can cause unpleasant symptoms. This is what most people mean when they talk about having hemorrhoids or “piles.” The most suitable type of treatment will depend on the size of the hemorrhoids and the severity of symptoms. Every approach has its own advantages and disadvantages. Depending on the procedure, side effects can occur – some more severe than others.

Sclerotherapy and “rubber band ligation” (“banding”) are generally carried out as day procedures, without an anesthetic. If someone has grade 3 or grade 4 hemorrhoids, doctors often recommend surgery. A general or local anesthetic is usually needed for this. You then have to stay in the hospital for a few days, and stay off work for some time too.

Sclerotherapy (injections)

Sclerotherapy might be considered as a treatment for grade 1 or grade 2 hemorrhoids. In this procedure, a proctoscope is gently inserted into the anus. A proctoscope is a short tube with a light on it which the doctor can use to look at the membranes lining the anus. Then, with the help of the proctoscope, a liquid containing drugs such as quinine, polidocanol or zinc chloride is injected into the area around the enlarged hemorrhoids. The aim of this procedure is to shrink the hemorrhoids by reducing their blood supply. It usually needs to be carried out several times in order to treat all of the enlarged hemorrhoids. The injections are typically given every few weeks.

After sclerotherapy, some patients experience bleeding, mild pain, pressure, or the feeling that there is something in their back passage. In rare cases this procedure can also lead to swelling or infections. Sometimes a painful blood clot (thrombus) forms in the anal region. In many people, the hemorrhoids grow again after two to three years.

Rubber band ligation (banding)

This approach is mainly used in the treatment of grade 2 hemorrhoids. It is also used for smaller grade 3 hemorrhoids, though. In rubber band ligation (also simply known as “banding”), the doctor first gently inserts a proctoscope into the anus. With the help of this instrument, he or she then places a small rubber band – only a few millimeters wide – around the base of the enlarged hemorrhoid. The band cuts off the blood supply to the hemorrhoid, which then shrinks and dies after three to five days. The dead tissue and rubber band fall off and leave the body in the stool, without you noticing it. This procedure generally has to be repeated in order to treat all of the enlarged hemorrhoids. Like sclerotherapy, it is carried out every few weeks.

Studies have shown that rubber band ligation has some advantages over other surgical procedures for the treatment of grade 2 hemorrhoids. The patients experienced less pain after the procedure and were able to return to work sooner. Possible complications following the procedure include pain, bleeding, thrombosis or abscesses. And in many people the hemorrhoids grow bigger again after this procedure, too.

Hemorrhoidectomy (hemorrhoid removal)

In this kind of operation, the enlarged hemorrhoids are removed (“ectomy” means “removal”) using instruments like scissors, a scalpel or a laser. In some approaches the wound is left open afterwards, in others it is partially or completely closed with stitches. Leaving the wound partially or completely open has the advantages of fewer stitch-related complications and fewer hematoma (bruising) problems. One disadvantage is that it takes longer for open wounds to heal.

Regardless of which operation they have, most patients experience pain in their anal region afterwards. Bowel movements and sitting can hurt as a result. These problems can usually be treated with painkillers. Other problems that may arise include bleeding after the operation, wound infections, abscesses, narrowing of the anus (anal stenosis), and – rarely – fecal incontinence. Fecal incontinence is the inability to control bowel movements.

Stapling

Stapling is a more recently developed technique, typically used in the treatment of grade 3 hemorrhoids. This procedure involves first removing some of the enlarged hemorrhoid tissue, and then “stapling” the remaining tissue to the lining of the anus again.

Recent research suggests that people who have this procedure experience less pain afterwards compared to people who have conventional surgery. They were also able to return to everyday activities sooner. But stapling was found to have a disadvantage too: the hemorrhoids grew bigger again sooner after the procedure, and also came out of the anus more often. So, compared to other surgical procedures, it might be necessary to repeat the stapling procedure sooner. Side effects like itching or bleeding were just as common following stapling as they were following other kinds of surgery.

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