Hemorrhoids, commonly known as piles, are a prevalent condition involving the swelling and inflammation of veins in the lower rectum or anus. This swelling is often caused by increased pressure, leading to symptoms like discomfort, itching, and bleeding. While hemorrhoids are rarely dangerous, they can significantly affect a person’s quality of life. Surgery is not the initial treatment and is generally reserved for severe cases where less invasive methods have proven ineffective or when acute complications arise.
Exhausting Non-Surgical Treatment Options
The first approach involves conservative, non-surgical methods aimed at reducing pressure and easing symptoms, typically addressing Grade I and Grade II hemorrhoids. This strategy includes increasing daily fiber intake (25–35 grams) to soften stool and promote regular bowel movements. Patients should also increase fluid intake and may use stool softeners to avoid straining, as straining exacerbates the condition.
Topical treatments like over-the-counter creams, ointments, or suppositories containing hydrocortisone or witch hazel can temporarily relieve pain and itching. Behavioral therapies, such as warm water sitz baths, where the anal area is soaked for 10 to 15 minutes several times a day, can also help reduce pain. Treatment is considered a failure when symptoms persist, recur frequently, or significantly impact daily life despite consistent adherence to these conservative measures.
When conservative care is insufficient, patients may be offered office-based procedures, such as rubber band ligation (RBL), often used for Grade I, II, and sometimes Grade III internal hemorrhoids. RBL involves placing a tight band around the base to cut off its blood supply, causing the tissue to wither and fall off. Other treatments include sclerotherapy (using an injected solution) and infrared photocoagulation (using heat). Surgery is considered when less invasive treatments fail to provide lasting relief or the hemorrhoids progress to a severe stage.
Medical Criteria That Warrant Surgery
Surgery is typically reserved for patients with severe conditions, most commonly Grade III and Grade IV internal hemorrhoids. Grade III hemorrhoids prolapse outside the anal canal and require manual reduction, while Grade IV hemorrhoids remain permanently prolapsed. Excisional hemorrhoidectomy is recommended for these advanced stages when conservative and office-based procedures have failed.
Acute complications also necessitate surgical consideration, such as a large external thrombosed hemorrhoid, where a blood clot forms within the tissue. Although some thrombosed hemorrhoids resolve naturally, excision within the first 72 hours of symptom onset offers rapid pain relief. A more urgent indication is a strangulated hemorrhoid, which occurs when a prolapsed hemorrhoid is trapped and its blood supply is cut off, potentially leading to tissue death if not treated promptly.
Surgery may also be warranted for severe chronic bleeding from internal hemorrhoids that leads to anemia. Recurrent hemorrhoidal disease that significantly compromises a patient’s quality of life, despite multiple non-surgical attempts, is another strong indicator for intervention. Surgery provides a high success rate for definitive, long-term resolution in these complex cases.
Understanding the Different Surgical Approaches
Once the decision for surgery is made, several procedures are available, each addressing the hemorrhoidal tissue differently. The traditional excisional hemorrhoidectomy, the standard for Grade III and IV hemorrhoids, involves the surgical removal of the tissue using a scalpel, scissors, or laser. This method offers a definitive solution with the lowest recurrence rate but is associated with the longest recovery time and the most post-operative pain.
Another option is stapled hemorrhoidopexy, or procedure for prolapse and hemorrhoids (PPH), used primarily for prolapsing hemorrhoids. This technique uses a circular stapling device to excise a ring of tissue above the hemorrhoid, lifting the prolapsed tissue back into its proper position. The procedure also disrupts blood flow, causing the hemorrhoids to shrink over time, and typically results in less post-operative pain than traditional excision.
Minimally invasive techniques like Hemorrhoidal Artery Ligation (HAL) or Transanal Hemorrhoidal Dearterialization (THD) focus on reducing the blood supply. A specialized Doppler ultrasound locates the feeding arteries, which are then tied off with sutures. This ligation causes the hemorrhoids to shrink over weeks and is often combined with a mucopexy, a stitching technique to lift and fix the prolapsed tissue. These techniques are less invasive and are associated with a quicker recovery and less pain compared to excisional surgery.
Recovery and Long-Term Care After Surgery
Recovery varies depending on the procedure, but patients generally anticipate two to four weeks before returning to most normal activities. The first few weeks are the most intensive, and most patients need one to two weeks off work to rest and manage discomfort. Pain is a common post-operative symptom, often peaking with the first few bowel movements, and is managed with prescribed medications and gentle wound care.
Patients may experience light bleeding or clear drainage from the anal area for up to several weeks as the surgical site heals. To promote healing and prevent complications, avoiding constipation is paramount, achieved by taking stool softeners, maintaining a high-fiber diet, and high fluid intake. Long-term care focuses on preventing recurrence by maintaining these lifestyle changes, including avoiding prolonged sitting and refraining from straining during bowel movements.