Diagnosis

After detecting the classic symptoms such as bright red blood on the toilet paper or stool and possibly itching and/or pain in the anal area, the doctor will perform a mirror image of the anus (anoscopy) and palpate the rectum with the fingers. Here, the hemorrhoids can usually be palpated. Hemorrhoids of the 2nd and 3rd degree also push themselves visibly outwards during pressing.

In most cases, these examinations are already sufficient to make a diagnosis, because as already described, almost all people suffer from hemorrhoids at an advanced age. However, if there has been a heavy bleeding or other circumstances, such as a family history or accompanying symptoms, suggest a possible malignant tumor, this suspicion is ruled out by performing a rectoscopy (proctoscopy) or a colonoscopy of the entire colon. In addition, an x-ray may be necessary after rectal introduction of contrast medium, which will clearly show any tumorous narrowing of the intestinal lumen.

Therapy for hemorrhoids

There are several options in the treatment of hemorrhoids, depending on the degree of the disease. Hemorrhoids are divided into different degrees of disease. Depending on the stage of the disease and the symptoms that occur, different treatment options are possible.

Treatment is only required if the hemorrhoids cause symptoms. The treatment of hemorrhoids is usually carried out by proctologists. The symptoms can be alleviated by keeping the stool soft and ensuring that the person concerned has regular bowel movements.This has the effect of avoiding strong pressing when going to the toilet, which is considered to be one of the causes of hemorrhoids.

A change in diet with an increased dietary fibre content and sufficient fluids are helpful in this regard. In addition, this is promoted by sporting activity. For less pronounced 1st and 2nd degree hemorrhoids, which only cause short-term symptoms, a drug therapy is usually sufficient at first.

Here, ointments, creams or gels are applied locally to the affected area. These contain anti-inflammatory agents and/or local anaesthetics to relieve pain and itching of the anus. Some medicines also contain cortisone as an active ingredient.

Here there is a risk of developing a fungal disease of the intestine. In addition, sitz baths with herbal additives, such as chamomile or oak bark, can provide relief. Suppositories are also used for local treatment.

Through this conservative treatment, the symptoms can be alleviated or even disappear completely. However, the hemorrhoids do not disappear. There are also other possibilities of conservative therapy.

These include, for example, the use of anal stretchers, which are intended to loosen up the tense shooting muscles. This improves the blood circulation in the anal region and alleviates the symptoms. A sclerotherapy is performed for 1st and 2nd degree hemorrhoids.

In this therapy the blood vessels are sclerosed by the injection of certain substances and the treated tissue dies. The hemorrhoid cushion becomes smaller as a result and can recede into the rectum. Several therapy sessions are necessary, which are usually performed at intervals of about four to six weeks.

The so-called rubber band ligature is also a treatment option. Here, the hemorrhoids are sucked in by the doctor and tied off with rubber bands. After a few days, the constricted tissue dies off and the hemorrhoid cushion becomes smaller.

Both methods of treatment are painless for the patient and do not require anesthesia or sedation. For grade 3 or 4 hemorrhoids, these conservative treatments or the small outpatient treatments are not sufficient to alleviate the symptoms. In this case, surgery with subsequent stay in the clinic is necessary (see below).

Surgery is also indicated for haemorrhoids for which the conservative measures do not provide any relief. The aim is to restore the normal anatomical conditions of the anal region, which are a prerequisite for continence. If the hemorrhoids have emerged from the anus to such an extent that they cannot recede, the tissue must be removed.

This is called hemorrhoidectomy. This requires general anesthesia or an anesthesia near the spinal cord (spinal anesthesia). For 3rd degree hemorrhoids, the so-called stacker method can also be used.

This is a special surgical procedure that is less painful and more comfortable for the patient. The anal skin is lifted internally with a special stapler. Another surgical method is the hemorrhoidal artery ligation.

This is a minimally invasive procedure in which the blood vessels supplying the hemorrhoids are ligated with the aid of an ultrasound probe. With this method, however, the hemorrhoids often reappear afterwards. A similar procedure is transanal hemorrhoidal artery dearterialization.

Hemorrhoid surgery is often followed by bleeding and pain in the anal region. Control over bowel movements can also be limited in the first few days. However, this changes after a few days.

To prevent a relapse, it is important to ensure that the stool is soft and shaped. This can be achieved by a diet rich in fiber and plenty of fluids. Local treatment of hemorrhoids is a purely symptomatic treatment that can improve the symptoms, but does not treat the underlying cause of the symptoms or prevent the disease from progressing.

Local therapy is used for irritation of the skin in the area of the anus and complaints such as itching, burning and weeping. For mild complaints, in addition to appropriate anal hygiene, an ointment treatment with a zinc paste can be applied. Cortisone-free ointments with the addition of a local anaesthetic can also be used.

For more severe complaints, cortisone containing ointments with an added local anaesthetic and astringent, drying agents such as bismuth are appropriate.For complaints caused by cracks in the anal canal skin (anal fissures), an ointment containing the active ingredient glycerol trinitrate (GTN) can also be applied. This ensures the relaxation of the sphincter muscle. If the therapy with an ointment leads to an aggravation of the symptoms or skin symptoms, it should be discontinued immediately, as active ingredients of the ointment or ointment additives can also cause allergic skin reactions.

A self-therapy with an ointment containing cortisone should be discontinued after a treatment period of 10 to 14 days, as otherwise permanent damage to the skin may occur. In general, a self-therapy with an ointment should not be carried out for longer than two weeks, since a proctologically trained doctor should be consulted at the latest after this period. There are numerous home remedies against hemorrhoids.

Marigold ointment is locally anti-inflammatory and promotes wound healing. Calendula ointment contains various substances such as calendulin, saponins and flavonoids and soothes irritated mucous membranes. Sitting baths are another way to alleviate hemorrhoidal problems.

For example, a sitz bath with oak bark extract, which is available in pharmacies, has a healing effect on hemorrhoids. If severe itching in the area of the hemorrhoids occurs, a cloth soaked in diluted fruit vinegar can provide relief. The application of sliced garlic cloves or the application of aloe vera juice can also reduce itching.

The application of grated ripe bananas to the hemorrhoids can also be helpful. Nutrition should also be taken into account with hemorrhoids. For example, a lot of fiber and whole grain products should be taken in.

A varied diet with lots of fresh fruit and vegetables is recommended. A tablespoon of olive oil after a meal can also stimulate digestion and prevent constipation. The intake of sufficient fluid throughout the day can additionally prevent aggravation of hemorrhoids.

Regular exercise and sports also have a positive effect on hemorrhoidal problems. If there are higher grade haemorrhoids, i.e. third or fourth grade, surgical therapy is the first choice. It must be considered whether the operation should be performed as an outpatient or inpatient procedure, as postoperative pain as well as other complications such as bleeding or wound healing disorders can occur.

Regardless of whether the procedure is performed as an outpatient or inpatient procedure, anesthesia is always indicated. There is the possibility of general anesthesia or regional or block anesthesia. There are four different surgical techniques to choose from depending on the findings.

Open segment removal after Milligan-Morgen (1937): Open segment removal after Milligan-Morgen can be used to treat segmental III. to IV. grade hemorrhoids.
In this procedure, the enlarged nodes and additionally the sensitive anal canal skin are completely resected in a short procedure lasting 10 to 30 minutes. The wounds are then left open and heal with scars after four to six weeks. The procedure can generally be performed on an outpatient basis, but in case of extensive findings or severe concomitant diseases of the affected person, a two to four-day stay in the clinic should be considered.

The disadvantage of open segment removal is the strong postoperative pain, which requires the intake of painkillers for a period of approximately one to two weeks. Pain during defecation can persist for up to six weeks after the procedure. The patient’s ability to work is also limited for a comparatively long time during this procedure, with an approximate duration of two to three weeks.
Closed segment removal according to Ferguson or Parks: In this surgical technique, the skin of the anal canal is incised and detached from the enlarged hemorrhoidal nodes.
In contrast to open segment removal after Milligan-Morgen, the skin of the anal canal is preserved and not removed. Due to this fact, this surgical method is preferred, especially when resection of several enlarged vascular nodes is indicated. Subsequently, the hemorrhoidal nodes are detached from the inner sphincter and removed after the feeding vessels have been tied off.

In the surgical technique according to Ferguson, the sensitive anal canal skin is then closed with a suture. If the anal lining unnaturally emerges from the anus, the anal canal skin is sutured to the mucous membrane of the rectum so that it is once again in the anal canal.This procedure is also known as Park’s hemorrhoidectomy. With the surgical technique according to Ferguson or Parks, postoperative pain is significantly less, wound healing is faster and the risk of scarring after the procedure is significantly lower than with open segment removal after Milligan-Morgen.

This type of surgery can also be performed on an outpatient basis, but a short hospital stay is recommended in the case of extensive findings or severe concomitant diseases.

Postoperative follow-up treatment: After a hemorrhoid operation, the anal region should be showered or a sitz bath should be taken after each bowel movement, but at least once a day. In case of postoperative pain, decongestant painkillers should be taken for one to two weeks. Depending on the operation, the patient should take it easy on his or her body for one to three weeks and not lift heavy loads.

If necessary, stool can be regulated, for example with light laxative middles.

Reconstructive hemorrhoid removal according to Fansler/Arnold: The reconstructive hemorrhoid removal according to Fansler/Arnold is used for hemorrhoids IV. Degree (permanent fixed prolapse of the hemorrhoidal tissue (prolapse)).
During the time-consuming procedure, which lasts approximately 40 to 60 minutes, a U-shaped anal canal skin flap is formed. The hemorrhoidal pads are then resected and finally the anatomy of the anal canal is restored. The reconstructive hemorrhoid removal according to Fansler/Arnold can only be performed in conjunction with an inpatient stay in hospital.

The disadvantage of this operation is a relatively high complication rate of 20%, because the created wound area is large. Therefore it is recommended to treat the hemorrhoids in time, so that such a comparatively large operation is not even indicated.
Circular stapler hemorrhoidopexy according to Antonio Longo (1993): Circular stapler hemorrhoidopexy according to Antonio Longo is performed with a ring-shaped stapler (circular stapler) and is now used in 25-30% of all hemorrhoid operations. It can be performed on grade III circular hemorrhoids including anal prolapse.
A precondition is that the hemorrhoids can be manually repositioned in the anal canal. This procedure has many advantages for the patient: the operation time is short (20-30 minutes), there is usually no pain postoperatively and the wound healing is faster than with the other procedures, so that the patient is able to return to work after one to two weeks. This operation should be performed in hospital with a subsequent inpatient stay.

There are a large number of homeopathic remedies that are said to have a positive effect on hemorrhoids.

Collinsonia Canadensis can provide relief from pain caused by excessively hard stool. Aesculus and Muriaticum acidum can be used for burning pain in the area of the hemorrhoids. Silicea can have a positive effect on cramp-like complaints and sore anus. Other homeopathic remedies used for hemorrhoidal disorders are Calcium phosphoricum, Potassium carbonicum, Lachesis, Nux vomica and Sulphur.