Ointments, creams, and suppositories
Even though they cannot "heal" haemorrhoids, several pharmaceutical preparations can soothe their symptoms, such as pain and itching:
- Mild emollient creams, ointments or suppositories can soothe pain.
- Preparations containing local anaesthetics (such as lidocaine) can help relieve acute pain: they should only be used for a short period (5-10 days) though, as they may cause sensitisation or irritation of the anal skin.
- Topical preparations containing corticosteroids can be prescribed by a physician in the event of an inflammation. Reducing the inflammation can help soothe soreness and itching. As for preparations containing anaesthetics, these too should not be used for a prolonged period of time.
Oral medications, such as flavonoids and synthetic seeds, can help improve vein tone, thus reducing vascular permeability and inflammation.
Parasurgical procedures and out-patient surgical procedures
Parasurgical procedures are performed in the early stages of symptomatic haemorrhoidal disease. Such treatments are suitable for internal haemorrhoid cushions, located above the dentate line, in an area where there are no sensory innervations. If they are performed correctly, such procedures should not be painful.
The most common procedures are rubber band ligation and injection sclerotherapy.
Rubber band ligation
With this procedure, which is usually performed by a surgeon in an outpatient clinic or office, a rubber band is placed at the bottom of the haemorrhoid. This cuts off the blood supply to the cushion, which necrotizes and falls off after a few days. Then the tissue underlying the haemorrhoid cicatrizes.
Rubber band ligation
Mild complications may occur: mild pain in the ano-rectal area, which disappears spontaneously; acute pain straight after the procedure is performed, which is a sure sign that the rubber band was not placed correctly; haemorrhoidal thrombosis (which is very painful); movements of the rubber band; slight bleeding and mucous ulcers.
Severe complications are quite rare and may include urine retention, rectal bleeding, perianal abscesses and pelvic sepsis. These major complications occur in about 2-3% of cases; the most frequent severe complication is a significant rectal haemorrhage, which usually occurs ten days after ligation. This requires hospitalization.
Sclerotherapy is an alternative to rubber band ligation and allows blood flow to the haemorrhoidal cushion to be reduced, thus decreasing the volume of the cushion. In addition to that, this method secures the mucosa to the underlying layers, thus reducing the prolapse.
Complications: the most common complications are temporary ano-rectal pain and a mild rectal haemorrhage in the first days after sclerotherapy.
More severe complications, which are quite rare though, include sub-mucous abscesses, blood in urine and impotence. Such complications may occur if the injections are not given in the correct position.
Infra-red photocoagulation, cryotherapy
Infra-red photocoagulation and cryotherapy, which can be alternatives to rubber band ligation and sclerotherapy, are offered as out-patient procedures. Nevertheless they are much less popular than rubber band ligation and sclerotherapy, and they are performed less frequently.
Although parasurgical procedures can be less painful and more tolerable than conventional surgical procedures, they are not effective for all haemorrhoid degrees and they show a high relapse rate.
Conventional surgical procedures
Milligan Morgan technique and Ferguson technique
In conventional surgical procedures a surgical ligation is performed at the bottom of haemorrhoids, which are then surgically removed. If they are properly performed, these procedures are very effective and can solve the problem once and for all, since they remove both internal and external haemorrhoids.
Such techniques are very painful in the post-operative period, because they leave three wounds in the perianal area, which cause acute pain during bowel movements.
The most common haemorrhoidectomy techniques are the Milligan-Morgan method and the Ferguson method.
In the Milligan-Morgan procedure, wounds are left open after surgery so that they can cicatrize spontaneously.
Milligan Morgan procedure
In the Ferguson procedure, wounds are closed with a running suture.
Complications are quite rare, but severe, and may include anal stenosis, haemorrhage and various degrees of incontinence.
This procedure was developed in an attempt to treat prolapsed haemorrhoids without excision or ligation of the haemorrhoidal tissue.
A mechanical stapling device is used in this technique, which was devised by Dr. Longo in the 90s. It is less painful and more "physiological" than conventional haemorrhoidectomy, since it implies no excision of the haemorrhoidal tissue.
Some specific complications may occur, such as post-operative haemorrhage, persistent ano-rectal pain, a compelling urge to defecate and in some cases rectal perforation.
THD - A painless surgical procedure to treat haemorrhoids
Transanal haemorrhoid dearterialization is the least invasive surgical technique to treat haemorrhoids, as it implies no tissue excision. A few internal stitches are given on the rectal mucosa, in an area where there are no sensory innervations.
For this surgical procedure a doppler is used to locate the terminating branches of the haemorrhoidal arteries. Once the artery is located, the surgeon uses an absorbable suture to ligate or "tie-off" the arterial blood flow. If haemorrhoids are prolapsed, a hemorrhoidopexy is performed to repair the prolapse and to "lift" the tissue back to its anatomical position.