Indications for intervention

Abstract

Most patients with hemorrhoids present with painless bright red bleeding. However, the diagnosis should never be assumed and should be arrived at only after a thorough and detailed history and physical examination as outlined in the chapter on diagnosis. "Diagnosis must precede any treatment," is an important surgical dictum which is occasionally forgotten in the heat of events, often with tragic consequences. Provided that the diagnosis is confirmed, the next challenge is to identify the severity of the patient's symptoms. The treatment must be tailored to the patient's problems. Certainly, it would be most inappropriate to perform a painful excisional hemorrhoidectomy in a patient who has an occasional asymptomatic prolapse and is otherwise not incapacitated by the disease. Since vascular anal cushions are a normal part of the anatomy, the term "hemorrhoids" should be confined to situations where these cushions are abnormally large and cause symptoms. In the absence of symptoms, even very large cushions do not require treatment. The old adage that it is hard to make an asymptomatic patient better applies here. A variety of treatment options are available for the treatment of hemorrhoids. Proper attention must be made in the selection of cases for any treatment options that are available. The selection depends upon the degree of discomfort that the patient is experiencing as well as an accurate assessment of the size and bulk of the hemorrhoids. Not every patient with hemorrhoids requires surgical intervention. Often patients with hemorrhoids suffer from minor symptoms which are inconvenient and unpleasant at most. A surgical hemorrhoidectomy in these patients would most certainly be an overtreatment. It would be akin to treating a fungal toe infection with an amputation! It is also important to understand the patient's expectations. Many patients who have mild symptoms are looking for reassurance that there is nothing more sinister going on. Once the evaluation is complete and other causes have been ruled out, these patients may not be interested in surgical intervention and can just be treated with education about healthy eating habits and good bowel habits. Common indications for intervention in patients with hemorrhoids include bleeding and prolapse. Other indications are mucus seepage and pruritis, fecal soiling and incontinence, pain and thrombosis, and anemia. These, along with some special situations, will be discussed individually. © Springer-Verlag London Limited 2009.