When do you need hemorrhoid surgery?

Hemorrhoids are a cluster of vascular tissues that act as a cushion in the lower part of the rectum that connects the rectum and anus. They are a normal part of the human anatomy.

Most people suffer from hemorrhoids in their lifetime but sometimes they can be very painful and discomforting: When do you need hemorrhoid surgery? Read more to know the answer to this question.

They are present to help with the stool movement by helping in the closing of the anal canal during increased pressure on the abdomen.

However, a sedentary lifestyle, bad eating habits, pregnancy, and lifting heavy objects; all these factors can contribute to increased pressure on the abdomen which puts more strain on the hemorrhoids, resulting in swollen and bulging hemorrhoids in the rectum and anal region.

The good news is mostly self-treatment or home remedies are good enough to deal with hemorrhoids.

When do you need hemorrhoid surgery
Photo by Andrea Piacquadio: https://www.pexels.com/photo/young-man-in-sleepwear-suffering-from-headache-in-morning-3771115/

Surgical treatment for hemorrhoids

When self-treatment and outpatient procedures such as rubber band ligation, sclerotherapy, and cauterization fail to treat the hemorrhoidal disease then a more serious treatment option is taken which is surgical treatment.

Hemorrhoidectomy is the surgical treatment to remove severe internal or external hemorrhoids.

It is performed in the following cases:

Thrombosed or clotted hemorrhoids: When blood gets trapped inside a hemorrhoid blood clots start forming. These types of hemorrhoids can be very painful while sitting, walking, or during a bowel movement.

Grade III and IV internal hemorrhoids: When a patient suffers from prolapsed hemorrhoids that do not go back inside on their own. This can be a very embarrassing condition for the patient along with being painful and discomforting.

Strangulated hemorrhoids: When blood circulation stops in internal hemorrhoids due to increased pressure on the blood vessels, blood accumulates in internal hemorrhoids and turns into clots. These can be painful and result in the bloody stool.

Minimum Invasive Procedures: Patients who do not respond to self-treatment and minimum invasive procedures.

What are the grades of hemorrhoids?

Grade I: These are internal hemorrhoids with no prolapse hemorrhoids.

Grade II: These types of hemorrhoids bulge out while straining during a bowel movement but go back inside themselves. These hemorrhoids are small prolapse hemorrhoids.

Grade III: These are prolapsed hemorrhoids that have to be manually tucked inside.

Grade IV: These are prolapsed hemorrhoids that do not go back inside and need hemorrhoidectomy for treatment.

What are medical procedures or minimum invasive procedures used for hemorrhoid treatment?

Rubber band ligation: It is an outpatient procedure meaning you get to go home the same day as it involves a very easy process. The doctor uses a device to place a rubber band at the base of hemorrhoid which stops the blood flow to the hemorrhoid due to which hemorrhoid shrinks and dies off in a few days’ time.

Complications:

  • Pain after the procedure is normal, paracetamol can be taken to avoid it
  • Bleeding due to hemorrhoids falling off, happens up to 2 weeks after the procedure
  • Infection that can give rise to pelvic sepsis
  • Clot formation inside hemorrhoids
  • Non-healing ulcer: Ulcer remains behind usually after hemorrhoids die off due to the rubber band ligation technique which heals themselves usually. However, in some cases, they do not recover and turn into non-healing ulcers

The patient recovers in about two weeks if no complication occurs. Rubber band ligation is one of the safest treatment routes and it also has a very short recovery time.

Post-procedure advice:

  • Patients can take paracetamol medication for pain or discomfort
  • Fiber supplement for smooth bowel movements
  • Avoid straining while bowel movements
  • Take a warm sit bath
  • Avoid lifting heavy objects

Sclerotherapy:

Sclerotherapy is the process of injecting a chemical solution ( sclerosing agent) into the hemorrhoid veins so that they will shrink in size and dissolve in the body. The body absorbs the shrunk veins naturally over time.

The procedure takes about 10 minutes as it is a minimum invasive procedure. This treatment has a good success rate and the chances of reoccurrence of hemorrhoids are very less too in this treatment.

As sclerosing agents work by causing inflammation in the veins so their leakage in the body or any other side effect can cause many complications.

Complications:

  • Clot formation in the veins and deep vein thrombosis
  • Vision problems
  • Allergic reactions
  • Skin necrosis: death of a large number of tissues due to lack of oxygen and blood. The skin becomes dark and discolored.

Cauterization:

The process involves cutting off the blood supply to hemorrhoid by striking it with extreme heat or cold using special devices. This technique kills the diseased tissue by extreme heat or cold.

Infrared cauterization involves striking hemorrhoids with infrared rays, the heat from the infrared beam cuts off the blood supply to the hemorrhoid leaving behind scar tissue that holds the veins from bulging in the anal canal. This process is used for internal hemorrhoids.

The process is also done using electric current or laser beams, the mechanism is the same though that is heating or freezing hemorrhoids and sealing off the wound.

This process is effective only for grade I and II hemorrhoids as there is a very high reoccurrence rate in grade III and IV hemorrhoids.

Complications:

  • Feeling of fullness or need to have a bowel movement
  • painful bowel movement and urination till the scar recovers
  • bleeding in the stool
  • pain during treatment is common
  • Infection

Depending on how serious your hemorrhoids are doctor decides whether or not you need surgery for their treatment. Grade III and IV will need surgical treatment mostly. Large external hemorrhoids and internal hemorrhoids that do not respond to self-treatment and medical procedures such as rubber band ligation, sclerotherapy, and coagulation therapy will also need surgical treatment.

What are the surgical treatments for hemorrhoids?

Stapled hemorrhoidopexy:

The procedure involves removing the diseased hemorrhoids, in a normal state hemorrhoids act as cushions in the anal canal and they help in the movement of stool. Sometimes due to strain, they become inflamed and swollen which causes pain and discomfort during bowel movements along with other complications.

As the name suggests, stapled hemorrhoidopexy involves stapling the internal hemorrhoids to reduce the blood flow to the internal hemorrhoids, it also cuts down the enlarged internal hemorrhoids and pulls back the prolapsed hemorrhoids.

Two new surgical procedures of Stapled hemorrhoidopexy are stapled transanal rectal resection (STARR) and procedure for prolapse and hemorrhoids (PPH), both of these are used in different circumstances.

Stapled transanal rectal resection (STARR) :

This procedure is used for patients with Obstructed defecation syndrome, a condition that causes difficulty in bowel movements, feeling of incomplete bowel evacuation, and straining while pooping. This condition can be caused by psychological reasons or anatomical changes in pelvic floor muscles.

Procedure:

STARR is a procedure for internal hemorrhoids, a surgical stapler is used to remove extra hemorrhoidal tissue to get rid of the anatomical disorders that are causing the obstruction in bowel movements.

Recovery:

The patients are hospitalized for 1-3 days and they recover in around 15 days after the surgery.

STARR has been very successful in most of the patients with minimum post-operative pain and discomfort and significant improvement in the symptoms of obstructive defecation syndrome (ODS).

Prolapse and hemorrhoids (PPH):

A circular stapler is used for the removal of affected internal hemorrhoids and pushing the prolapsed hemorrhoids back to their anatomical position. This procedure is indicated in patients with grade III and IV internal hemorrhoids, patients who are not responding to the self-treatment, and medical procedures, who need surgical treatment.

Procedure:

A circular stapler is inserted in the anal canal where it removes extra hemorrhoidal tissue and repositions the rest of the affected hemorrhoidal tissue. The patient is given general anesthesia during the surgery.

Recovery:

The patient is allowed to leave the hospital and go home the same day or the next day. It takes a few days to go back to normal activities and about 2 days for the first bowel movement in some patients.

Passing staples during a bowel movement is normal after PPH surgery.

Complications:

  • Bleeding in the stool is one of the most common postoperative complications
  • Pain and discomfort during bowel movement
  • Urine retention
  • Irregular bowel movement (Constipation and diarrhea)
  • Anal fistula: a narrow tunnel between the anal canal and skin near the anus, it can cause infection and pus drainage.

Hemorrhoidectomy:

It is the surgical removal of the grade III and IV internal and external hemorrhoids. This treatment option is used if the patient has large external hemorrhoids. The procedure is performed under general anesthesia.

Recovery:

The postoperative pain is more than other treatment options for hemorrhoids. The surgical excision of hemorrhoids lefts behind a considerable amount of pain which requires about 2-4 weeks to recover.

However, hemorrhoidectomy has been a very successful surgical treatment option for patients with large external hemorrhoids and the reoccurrence rate is low too.

Complications:

  • Fecal incontinence: Since the surgery involves cutting and removing muscles from the anal canal, hence, if the surgery is not performed properly then the patent can lose control over bowel movement.
  • Blood in the stool: A little blood in the stool is normal during bowel movements but too much blood loss is not normal and causes anemia.
  • Anal fistula
  • Narrowing of the anal canal (anal stenosis)
  • Urine retention
  • Pain and discomfort

Postoperative advice:

Warm Sitz bath: Urine retention is common after the surgery, try urinating during sitz bath as urine retention can cause permanent damage to the urinary bladder. Visit the hospital if urine retention is severe to avoid any irreversible complications.

Bowel movement: first bowel movement after surgery is very difficult as there is fresh pain. The doctor will advise you to take a high fiber diet, drink enough water, and take laxatives if needed. Also, prescription medications for pain will be given.

Bleeding: It is normal for the patient to pass some blood after the surgery during the bowel movement. However, if the bleeding does not stop visit your doctor immediately.

About the author

Deepanshu has a Master's in chemistry. He has worked extensively on research subjects regarding cancer and radio nuclear science and has continually reviewed nutrition science.

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