The treatment of haemorrhoidal complaints forms a central part of our coloproctological practice. Haemorrhoids themselves are cushioning vessels lying in the upper margin of the anal canal. Arteries supply them with blood, veins carry the blood away. These veins pass through the interior sphincter: even if it is only slightly tensed, blood will accumulate in the haemorrhoidal cushions and the haemorrhoids become enlarged. The mucous membranes in the upper margin of the anal canal then close up, sealing off the rectum. Without needing to exert much muscular pressure, we are thus continent even for liquid stools and gases. When we evacuate our bowels (defecate), the interior sphincter relaxes to let the stool pass through it. Since the veins are no longer compressed, the cushioning vessels can also drain off, resulting in an immediate reduction of the swelling. As we can see, our haemorrhoidal cushioning vessels are important.
A special case: an acute swelling of the haemorrhoids is also called thrombosis.
This system can clearly be disrupted very easily, since haemorrhoids cause discomfort when they become enlarged.
Haemorrhoidal complaints have four degrees of severity:
|Grade 1||Haemorrhoids are enlarged, but do not protrude from the anal canal if pressure is applied.|
|Grade 2||Haemorrhoids are exposed if pressure is applied, but retract again if the patient relaxes.|
|Grade 3||Haemorrhoids prolapse if pressure is applied and require manual reduction to assume their original position.|
|Grade 4||The haemorrhoidal cushions have been prolapsed for such a long time that they can no longer be returned into the anal canal even with the help of a finger.|
The textbook symptoms are:
- Itching/burning sensation around the anus: The mucus from the mucosa leaks onto the external skin, moistening and irritating it. This leads first to reddening and then to lasting skin changes.
- Feeling of pressure, urge to defecate: The enlarged cushions stretch the anal canal and stimulate its stretch receptors. Under normal conditions, these receptors warn us that we should try and get to the toilet as soon as possible.
- Bleeding: The mucosa above the haemorrhoidal cushions are thin and therefore easily damaged. This easily explains why bleeding can occur if the enlarged cushions protrude into the anal canal. Bleeding can be very heavy: in such cases, patients should seek medical advice from a specialist clinic (such as ours) or a hospital.
Treatment for haemorrhoidal complaints always depends on their degree of severity. We can offer you the following types of treatment:
Sclerosis: Also known as sclerotherapy, this treatment uses the fact that scar tissue pulls together. The doctor sprays tiny doses of alcohol or an oil solution onto the upper edge of the haemorrhoidal cushion. This can be painful for the patient, so only minimal amounts are used. For this reason, however, the treatment must generally be repeated 3–4 times.
Rubber band ligation: Here, a special “gun” is used to create a vacuum that sucks the excess tissue into a small chamber. Once captured, a very strong rubber ring is dropped onto the tissue, forming a tight band (= ligature) around it. This creates a large pea-sized object that is cut off from the body’s blood supply because the rubber ring pinches the tissue very tightly. The tissue therefore dies and drops off after 1–2 weeks. This treatment is reserved for enlarged first- or second-degree haemorrhoids only. The risk of bleeding is higher for patients taking medication containing phenprocoumon or aspirin/clopidogrel. Accordingly, we do not use this treatment for this patient group.
- Previously, haemorrhoidectomy (e.g. Milligan-Morgan, Parks methods) of the enlarged haemorrhoidal cushions was the standard surgical procedure: the various methods produce largely the same results. These are a good option for (esp. third- and fourth-degree) segmental haemorrhoids in male patients. Other procedures have since become available, of which the most important is the method termed
- Stapled haemorrhoidopexy. This does not result in an open wound in the anal canal and pain from surgery generally wears off more quickly. In our opinion, this procedure is the best choice for circular second- and third-degree haemorrhoids, especially if all three afferent arteries have led to enlarged cushions.
- With a mono- or bisegmental presentation we perform an open, segmental haemorrhoidopexy using the Pakravan-Helmes method.
- For fourth-degree – fixed – haemorrhoidal cushions, the closed procedure is often inadequate and so we perform an “anoproctoplasty” using the Fansler-Arnold method. This is a more complex surgical procedure: with a pronounced condition, multi-stage surgical treatment may be necessary.
Treatment with suppositories and ointments never leads to a reduction in the cushions and thus a cure. Such applications do provide considerable pain relief for the patient, however, and are thus part of the course of treatment.