In addition to high-fiber diets and influencing defecation behavior, several drug treatment options are available. Internally, flavonoid-containing combination preparations of diosmin and hesperidin have been shown to be effective. Perianal or rectal hemorrhoidalia are used for symptomatic relief of symptoms. Other non-surgical methods include sclerotherapy and rubber band ligation.
Hemorrhoidal disorders are among the five most common proctological diseases in highly industrialized countries [1]. The superior hemorrhoidal plexus or corpus cavernosum recti is a spongy vascular cushion that plays an important role as part of the continence organ in relation to the fine sealing of the anus. If enlarged arteriovenous vascular cushions cause discomfort, this is referred to as hemorrhoidal disease. Symptomatic hemorrhoids are thought to affect up to 70% of all adults at some point in their lives [2]. Common symptoms include peranal bleeding, perianal swelling or prolapse, and itching, oozing, or burning. Basic proctological examinations are useful for diagnosis. If the hemorrhoids are of low grade, conservative therapy is sufficient in most cases; in the case of higher grade hemorrhoids, surgical intervention may be necessary. The new S3 guideline published last year under the auspices of the German Society of Coloproctology in collaboration with other professional societies from Germany, Switzerland and Austria contains evidence-based recommendations on key aspects of the management of hemorrhoidal disease [2].
Peranal bleeding must be clarified
Depending on the increase in size and the extent of the prolapse into the anal canal or in front of the anus, respectively, a division into 4 degrees are made, whereby the stage transitions are fluent (Overview 1). The main symptom of hemorrhoidal disease is peranal bleeding, which requires clarification because the color of the blood and the intensity of the bleeding do not allow definite conclusions to be drawn. Pain is not a typical symptom of enlarged hemorrhoids, but is caused, for example, by accompanying fissures or thromboses. The most reliable assessment is ensured by a basic proctological examination with history, inspection, palpation and proctoscopy [4]. Assessment of hemorrhoidal stage during colonoscopy is not recommended. The stage is decisive for the choice of therapy; surgical intervention is rarely required. In low-grade hemorrhoids (grade 1 or 2), spontaneous complete or partial remission is not uncommon [5]. However, especially in higher stages, hemorrhoidal disease often leads to a progression of symptoms if left untreated. Therapeutic goals include reduction of recurrence or residual symptoms, prevention of complications, reduction of pain, improvement of quality of life, and patient satisfaction [6].
Diosmin/hesperidin effective for acute hemorrhoidal symptoms
Diet, defecation behavior, and stool regulation appear to play a role in baseline therapy. It is recommended that patients be advised of the benefits of a high-fiber diet or appropriate stool regulation (Plantago ovata, psyllium) [2]. In addition to dietary changes, correction of defecation behavior with avoidance of clenching and prolonged sessions has been shown to be beneficial.
Among the medicinal measures , flavonoids are among the most commonly used oral substances. According to the guideline, diosmin/hesperidin can be used for acute hemorrhoidal symptoms and postoperatively. Daflon® 500 mg is a flavonoid mixture of diosmin and hesperidin, which is believed to have a triple effect on the venous return system. First, it induces an increase in tonicity at the veins and venules, which counteracts congestion. Secondly, at the level of the lymphatic system, lymphatic drainage is stimulated by improving lymphogenic activity. Third, at the level of microcirculation, capillary resistance is increased and capillary permeability is normalized. In a Cochrane review published in 2012, an analysis of 24 randomized-controlled trials showed positive effects on low-grade hemorrhoidal disease and postoperative discomfort [7]. For hydroxylated flavonoid mixtures, the guideline mentions rutosides and ß-hydroxyethylrutosides, which are available as a combination preparation (oxerutin: Venoruton® 500 mg) or as a single substance.
In the case of the “hemorrhoidalia” to be applied perianally or rectally is another group of substances that contains a wide variety of active ingredients and is primarily used for the symptomatic treatment of possible concomitant complaints (e.g. inflammatory or edematous changes) in hemorrhoidal disease [8]. Ointments, creams, suppositories, and anal tampons (suppositories with a trough insert) are available as dosage forms, which are applied perianally or rectally depending on the administration; corresponding active ingredients are either local anesthetics (e.g., lidocaine) or antiphlogistics (e.g., corticosteroids) [9]. The ointment (Procto-Glyvenol®), to be applied locally or rectally, is composed of a flavonoid (tribenoside) and a local anesthetic (lidocaine) and is judged useful in low-grade hemorrhoidal disease in a literature review by Lorenc [10].
Sclerotherapy and rubber band ligation as further measures
The principle of action of all interventional therapies is sclerotherapy or ligation of the feeding vessel as close as possible to the finding and/or removal of excess tissue while avoiding extensive wound healing [1]. The therapeutic effects of sclerotherapy are based on the induction of fibrosis, resulting in fixation and stabilization of the hemorrhoidal convolute above the linea dentata. The most common side effects are urologic complications such as prostatitis, hematuria, and urinary retention [11]. In suprahemorrhoidal sclerotherapy (injection or sclerotherapy), a phenol solution together with a carrier substance of almond or peanut oil is injected paravasally through a proctoscope as a sclerosing agent in the area of the arteries supplying the hemorrhoidal cushions. In intrahemorrhoidal sclerotherapy, the sclerosing agent is also injected submucosally directly into the hemorrhoidal cushions via a proctoscope using a syringe drop by drop. Nowadays, polidocanol solutions are most commonly used (e.g., Aethoxysklerol® 3%) or more concentrated alcoholic polidocanol solutions [12] (Overview 2). Since the tissue above the dentate line does not have any free nerve endings, the injections are basically painless.
Rubber band ligation can achieve similar short-term results as surgery, especially for 2nd-3rd degree hemorrhoids [2] (overview 3). In this procedure, aspirated tissue is tied off with a small rubber ring using a special ligation device (nowadays, endoscopic ligations are also possible). A few days later, the dead tissue falls off and the remaining wound scars and shrinks. The procedure results in reduction of excess hemorrhoidal tissue and simultaneously leads to reduction of the dislocated anoderm. The main complications mentioned are pain and bleeding. Local infiltration with local anesthetics can be used to prevent postinterventional pain after rubber band ligation. For 2nd degree hemorrhoids, rubber band ligation is considered the treatment of choice; for 1st and 3rd degree hemorrhoids, this technique can also be used.
“Sliding anal lining” theory
Even though hemorrhoidal disorders are common, the etiopathogenesis has been insufficiently scientifically proven. Data on various possible causes and pathogenetic changes are controversial [2]. The etiopathogenetic involvement of the following factors is discussed: arteriovenous fistulas or hypervascularization; changes in the anal sphincter or intraanal pressures; cellular changes; degenerative, inflammatory and/or metabolic changes in collagen fibers and elastic fibers; pregnancy; genetic factors. Individual studies have examined the factors of diet, BMI, or alcohol consumption. Nowadays, the widely accepted theory for the development of hemorrhoidal disease is the assumption of a progressive distal displacement of the hemorrhoidal plexus (“sliding anal lining” theory according to Thomson) [3], which has replaced the earlier assumption that hemorrhoids have the same pathogenesis as varicose veins. According to the “sliding anal lining” theory, hemorrhoids are the result of a breakdown of muscular and elastic components leading to a pathological displacement and enlargement of the corpus cavernosum recti in the distal direction of the anal canal [3].
Literature:
- Antje Lechleiter A, Studer P, Brügger L: Per se not in need of treatment! Hemorrhoids – where are we today? Swiss Med Forum. 2019;19(4748):766.
- Joos AK, et al: S3 guideline – hemorrhoidal disease. AWMF 2019, www.awmf.org
- Thomson WH: The nature of haemorrhoids. Br J Surg 1975; 62(7): 542-552.
- Oberhofer E: First S3 guideline on hemorrhoidal disease. In the vast majority of cases, conservative therapy is sufficient! hautnah dermatologie volume 35, pages 58-59(2019)
- Jensen SL, et al: The natural history of symptomatic haemorrhoids. Int J Colorectal Dis 1989; 4(1): 41-44.
- Jongen J, Kahlke V: Quality indicators in the treatment of hemorrhoids. The Surgeon 2019; 90; 264-269.
- Perera N, et al: Phlebotonics for haemorrhoids. Cochrane Database Syst Rev 2012; 8: CD004322.
- Wienert V: Proctological pharmacotherapy. coloproctology 2002; 24: 318
- Wienert V: Externa-basic substances of proctological preparations. Colo-Proctology 2003; 25(1): 39-41.
- Lorenc Z, Gokce O: Tribenoside and lidocaine in the local treatment of hemorrhoids: an overview of clinical evidence. Eur Rev Med Pharmacol Sci 2016; 20(12): 2742-2751.
- Al-Ghnaniem R, Leather AJ, Rennie JA: Survey of methods of treatment of haemorrhoids and complications of injection sclerotherapy. Ann R Coll Surg Engl 2001; 83(5): 325-328.
- ABDA (ed.): New prescription Formularium 5.8.: Ethanol-containing 600-polidocanol sclerosing solution 10%. Eschborn: GoviVerlag 2012.
GP PRACTICE 2020; 15(10): 24-25.
