Do we at all need surgery to treat thrombosed external hemorrhoids? Results of a prospective cohort study

Abstract

Background: It is unknown whether surgery is the gold standard for therapy of thrombosed external hemorrhoids (TEH).

Methods: A prospective cohort study of 72 adults with TEH was conducted: no surgery, no sitz baths but gentle dry cleaning with smooth toilet paper after defecation. Follow-up information was collected six months after admission by questionnaire.

Results: Despite our strict conservative management policy 62.5% (45/72) of patients (95% confidence interval [CI]: 51.0-74.0) described themselves as "healed" or "ameliorated", and 61.1% (44/72, 95% CI: 49.6-72.6) found our management policy as "valuable to test" or "impracticable". 13.9% (10/72, 95% CI: 5.7-22.1) of patients suspected to have recurrences. 4.2% did not know. Twenty-two of the 48 responding patients reported symptoms such as itching (18.8%), soiling (12.5%), pricking (10.4%), or a sore bottom (8.3%) once a month (59.1%, 13/22), once a week (27.3%, 6/22), or every day (13.6%, 3/22).

Conclusions: The dictum that surgery is the gold standard for therapy for TEH should be checked by randomized controlled trials.

Keywords: acute hemorrhoidal disease; conservative therapy; hemorrhoids; perianal thrombosis; surgery; thrombosed external hemorrhoid.

Figure 1

All six photos are taken from the same patient. In three-day intervals, they show the healing of a perforated and bleeding single thrombosed external hemorrhoid within nine days of a patient who consequently complied to our strict conservative management policy. A) Day 0: The patient is in knee–chest position, head left. Right-lateral of the anus parts of the uninflamed external hemorrhoidal plexus are protruding. Left-lateral there is edematous tissue with a dark spot (nonperforated thrombosed external hemorrhoid) with a subcutaneous clot. B) Day 3: Perforation and anal bleeding occurred in between. Right-lateral of the anus parts of an unaltered external hemorrhoidal plexus are seen. Left-lateral redness and edema of inflamed anal skin perforated by two black clots. C) Day 6: The right-lateral parts of the external hemorrhoidal plexus remain unchanged. The left-lateral clots are still at same position. D) Day 6: Both clots were taken out. A gaping lesion remains at former perforation site. E) Day 9: A 2–4 mm healing lesion is seen at former perforation site. At right-lateral, unchanged parts of the external hemorrhoidal plexus. F) Day 32: At follow-up four weeks later, the left-lateral perforation can hardly be seen. At right-lateral, the uninflamed subcutaneous external hemorrhoidal plexus appears unchanged.