Hemorrhoidal Disease – A Civilization Illness Responsible for Perianal Discomfort
According to estimates, almost every second Czech will experience at least one attack of hemorrhoidal disease. Symptomatic hemorrhoids are found in about 5% of the population. Prevalence depends to some extent on lifestyle and dietary habits.
Manifestations of Hemorrhoidal Disease
Hemorrhoidal disease is caused by varicose-expanded arteriovenous plexuses in the anorectal area. Hemorrhoids are classified as external and internal based on anatomical location. Most patients visit doctors with issues caused by internal hemorrhoids, which are located above the linea dentata. A smaller percentage of patients have external or mixed hemorrhoids.
External hemorrhoids, caused by thrombosis of subcutaneous perianal plexuses, are covered by skin. They can affect the entire anus but more often appear as semi-spherical swelling at the anocutaneous junction, which the patient can feel. They typically present as sudden pain and tension localized to the edge of the rectum. The pain is generally intense, constant, non-pulsating, and not related to defecation. Examination reveals a bluish, firm subcutaneous swelling that is painful to palpation, sometimes with surrounding redness and swelling. Necrosis and spontaneous perforation, accompanied by bleeding that brings relief, can occur. Unlike internal hemorrhoids, external hemorrhoids do not typically bleed. After the symptoms subside, there may be a painless skin tag resulting from localized distention of the rectal edge epidermis. Large and multiple skin tags can complicate perianal hygiene and promote local maceration.
Internal hemorrhoids can be asymptomatic but are the most common cause of enterorrhage. Bright red blood may coat the stool, appear on toilet paper, or drip into the toilet during or after defecation. Bleeding tends to be intermittent and can lead to chronic anemia. Internal hemorrhoids are painless; patients feel them when they prolapse into and out of the anal canal, experienced as pressure or resistance. Depending on the severity, prolapse initially occurs only during defecation, later during standing and walking, and eventually becomes permanent. Initially, spontaneous reposition occurs, but manual repositioning is necessary, and eventually, it becomes impossible. Prolapse may also cause less specific symptoms such as mucous discharge, itching, stool staining, even incontinence. Complications include thrombosis and inflammation; inflamed nodes become swollen and severely painful. Pain and edema are exacerbated by reflex anal sphincter spasm.
Examination involves inspecting the perianal area, digital rectal examination, and rectoscopy or colonoscopy as hemorrhoids can mask rectal tumors.
Current Treatment Options
Hemorrhoidal disease treatment includes conservative, semi-conservative, and surgical methods.
Conservative therapy primarily involves lifestyle changes. Increasing fiber and fluid intake aims to ensure regular, soft stools, possibly supplemented with mild laxatives. Weight reduction and meticulous perianal hygiene are also important. Local therapy with ointments and suppositories can be used for symptom relief, although their long-term efficacy is limited. Pharmacotherapy benefits are observed with venotropics, especially those containing micronized diosmin, which is defined by the European Pharmacopoeia as a flavonoid mixture mainly composed of diosmin, hesperidin, and other flavonoids. These venotropics increase vascular wall resistance and have anti-inflammatory and hemostatic effects, useful in both acute and chronic hemorrhoidal disease.
Semi-invasive methods include outpatient procedures such as ligation (e.g., Barron ligation), sclerotherapy, laser therapy, or photocoagulation for patients with internal hemorrhoids.
Surgical methods still in use today include Longo's procedure, suitable for patients with second and third-degree internal hemorrhoids, and hemorrhoidectomy.
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Sources:
1. Rutar P. Hemorrhoidal disease and treatment options. Internal Medicine 2019; 21 (2): 128–130.
2. Korbička J., Chalupník Š., Cagaš J. et al. Hemorrhoids. A common and unpleasant disease – conservative therapy, surgical methods. Medicine for Practice 2012; 9 (12): 482–489.
3. European Pharmacopoeia (Ph. Eur.) 8.3 (01/2015): 4297–4298.
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