Note: Primary asymptomatic hemorrhoids should not be treated invasively [S3 guideline]. Surgery is required in only about 5% of all cases. The following recommendations are based on the current S3 guideline. For hemorrhoids of I. to II. degree is performed:
- Suprahemorrhoidal sclerotherapy (injection or sclerotherapy) – inducing a reduction in the size of hemorrhoids by injecting polidocanol in alcoholic solution.
- In principle, the injections are painless, because the tissue above the linea dentata (anatomical boundary line in the anus) has no free nerve endings.
- Sclerotherapy can be repeated, sometimes several times depending on the success of the therapy.
- Infrared therapy (IR; ICR; IPC; synonym: infrared coagulation) – sclerotherapy of hemorrhoids by infrared radiation.
- For hemorrhoidal disease of I. to III. degree, infrared therapy is comparable to rubber band ligation [S 3 guideline].
- Diathermy, electrocoagulation – direct monopolar coagulation of the hemorrhoidal node.
- Cryotherapy (synonym: cryohemorrhoidectomy) – freezing therapy using special probes.
- During subsequent rewarming, destruction of the cell membrane occurs, resulting in consecutive cell death.
- The procedure should not be used to treat hemorrhoidal disease.
- The procedure can also be used to treat bleeding in low-grade hemorrhoidal disease.
- Radiofrequency ablation (RFA) – radiofrequency waves cause heating of intracellular water until vaporization (evaporation).
- Based on the evidence currently available, no recommendation can be made for radiofrequency ablation.
- Laser therapy – Based on the currently available evidence, no recommendation can be made for the various laser procedures.
- Rubber band ligation (GBL) – Interruption of the blood vessels leading to the hemorrhoid; Indication: hemorrhoids 2nd (to 3rd ); Recurrence rate about 40%Note: GBL has a not insignificant risk of bleeding compared to sclerotherapy. When taking acetylsalicylic acid (ASS) GBL is still justifiable, but not under clopidogrel or Marcumar.
In hemorrhoids II to III degree is performed:
- Rubber band ligation (GBL)
- Hemorrhoids II. Grade: GBL is considered the therapy of choice.
- Hemorrhoids II to III degrees: GBL should usually be preferred to sclerotherapy because of the better success rate. Note: “Rubber band ligation can achieve short-term results similar to those achieved with surgery, especially for hemorrhoids of II to III degrees.”
- (Hemorrhoidectomy) – see below conventional surgical procedures.
For hemorrhoids III to IV degree is performed:
- Conventional surgical procedures/hemorrhoidectomy – peeling of the hemorrhoidal nodes and interruption of the feeding vessels.
- Indication: surgical therapy for hemorrhoidal disease is indicated when conservative procedures fail to provide adequate relief of symptoms [S3 guideline].The following procedures are available [S3 guideline]:
- Segmental resection procedures:
- Milligan-Morgan (MM) open hemorrhoidectomy; Milligan-Morgan segmental excision should not be combined with sphincterotomy (incision/incision of the sphincter) because of increased incontinence rates (inability to hold stool).
- Closed hemorrhoidectomy according to Ferguson (FG); does not represent a standard method and should be reserved for special indications.
- Subanodermal hemorrhoidectomy according to Parks (PA).
- The three surgical techniques mentioned should be considered equivalent.
Circular resecting procedures:
- (Circular) stapler hemorrhoidopexy according to Longo (CS); should no longer be performed due to high incontinence rates of 50%.
- Fansler-Anderson/Arnold reconstructive hemorrhoidectomy (FA).
- Whitehead hemorrhoidectomy (WH); is associated with a high rate of continence disorders as well as mucosal entropion and should not be performed
- Segmental resection procedures:
- Indication: surgical therapy for hemorrhoidal disease is indicated when conservative procedures fail to provide adequate relief of symptoms [S3 guideline].The following procedures are available [S3 guideline]:
Postoperative pain control
- Topical therapy with glycerol trinitrate; alternatively, topical calcium antagonists such as diltiazem.
- Postoperative administration of swelling agents to regulate stool to reduce postoperative pain.
Further notes
- The stapler procedure should be offered as a procedure for circular third-degree hemorrhoidal disease [S3 guideline].Do not use the procedure for hemorrhoids IV. Grade, because the recurrence rate (rate of recurrence) is higher compared to conventional surgery.
- Sphincterotomy (incision/incision into the sphincter muscle) – should not be used in combination with hemorrhoid surgery or as the sole therapy in the treatment of hemorrhoidal disease.
- Anal dilatation (dilation of the anus) as a therapy for hemorrhoidal disease should not be used because of a high rate of continence disturbance
- Only about 10% of patients with hemorrhoidal disease have an indication for surgery.
