Clinical practice. Hemorrhoids

miR-412-5p targets Xpo1 to regulate angiogenesis in hemorrhoid tissue

Hemorrhoid is a common and recurrent proctological disease, which is often accompanied by angiogenesis and edema. MicroRNAs in the DLK1-DIO3 imprinted clusters are involved in the development and pathogenesis of mammalian hemorrhoids. Results of the present study indicated multiple, differential expression of DLK1-DIO3 imprinted cluster microRNA between hemorrhoid and normal tissues, where miR-412-5p expression in hemorrhoid tissue was significantly decreased. Fluorescein reporter assays showed that miR-412-5p silenced Xpo1 mRNA expression by targeting its 3'-UTR. Overexpression of miR-412-5p in human umbilical vein endothelial cells (HUVECs) indicated that proliferation, migration and formation of vascular structures in HUVECs were inhibited in vitro. In addition, overexpression of miR-412-5p significantly inhibited Xpo1 expression and promoted upregulation of the p53 protein and its retention in the nucleus. Simultaneously, expression of p66SHC and p16 proteins was activated. In summary, downregulation of endogenous miR-412-5p expression in hemorrhoid vascular endothelial cells leads to high expression of the target gene Xpo1 and translocation of the p53 protein out of the nucleus, rendering it unable to activate p66SHC and p16. This ultimately weakens regulation of the vascular endothelial cell cycle, thereby accelerating the division of hemorrhoid vascular endothelial cells, leading to angiogenesis.

Classification and guidelines of hemorrhoidal disease: Present and future

Classification and guidelines of hemorrhoidal disease are based on the subdivision in Grades of prolapse followed by any aspect related to both the treatment and its technique. When taking the proposals for classification and guidelines issued by prolific scientific societies into consideration, it is evident that strong contradictions and interpretative limits emerge in finding the best treatment to be adopted. After a critical examination of these limitations, a methodological proposal is shared to achieve a new classification, which plays a part in forming a new guideline for hemorrhoidal disease, identifying its evolution, dynamism of the prolapse, symptomatology, enteropathogenesis and gender characteristics.

Perioperative Adverse Events in Women Undergoing Concurrent Hemorrhoidectomy at the Time of Urogynecologic Surgery

OBJECTIVE

The aim of this study was to describe the incidence and trends of outcomes after concurrent surgeries for symptomatic hemorrhoids and pelvic floor disorders.

METHODS

This was a retrospective matched cohort study. Women who underwent concurrent vaginal urogynecologic and hemorrhoid surgery between 2007 and 2017 were identified by their surgical codes and matched to a cohort of women who underwent vaginal urogynecologic surgery only. The medical record was queried for demographic and perioperative data.

RESULTS

Thirty-three subjects met the inclusion criteria; 198 subjects were matched accordingly (N = 231). Mean age and body mass index were 57 ± 12 years and 28.9 ± 5.6 kg/m, respectively. Subjects who underwent concurrent hemorrhoidectomy were more likely to have had previous prolapse surgery (27.3% vs 15.2%, P = 0.09) and preoperative fecal incontinence (27.3% vs 13.6%, P = 0.05). Concurrent cases were more likely to have unplanned office visits (27.2% vs 12.6%, P = 0.03) and phone calls (range, 1-7 vs 0-10; P = 0.001), mostly for pain complaints. Reoperation was higher in combined cases (3% vs 0%, P = 0.01); however, the overall rate of serious perioperative adverse events was low and not different between groups. Concurrent cases were more likely to be discharged home with a Foley (42.4% vs 18.2%, P = 0.002) and to have a postoperative urinary tract infection (33.3% vs 10.6%, P = 0.005). In the concurrent group, 33.3% of the patients experienced severe rectal pain.

CONCLUSIONS

Patients undergoing concurrent hemorrhoidectomy at the time of vaginal urogynecologic surgery are at higher risk of minor events such as postoperative urinary tract infection and need for discharge home with a Foley, as well as risk of pain that may be greater than urogynecologic surgery alone.

Ultrasound-Guided Needle Electromyography of the External Anal Sphincter

BACKGROUND

Anal sphincter needle electromyography (EMG) is a useful tool to evaluate various neurologic lesions. However, landmark-based needle placement has risks of missing the intended target including risk of bowel penetration. Ultrasound guidance has been widely used to enhance needle placement for various interventional procedures, but it has not been previously reported for use in anal sphincter EMG.

OBJECTIVE

To demonstrate the accuracy of ultrasound-guided needle insertion into the external anal sphincter (EAS).

DESIGN

Observational study.

SETTING

Tertiary care university hospital.

PARTICIPANTS

A single live male participant and six fresh cadavers.

METHODS

A preliminary study was conducted in a single live male participant to investigate the utility of ultrasonography imaging for the EAS and proper transducer location. After this preliminary study, 12 sides of the EAS in six fresh cadavers were assessed. A hooked fine wire was inserted into the EAS under ultrasound guidance.

MAIN OUTCOME MEASURES

Accuracy of needle placement was assessed after cadaver dissection.

RESULTS

The EAS was easily identified with ultrasound in preliminary and cadaver studies. The needle tips were located in the EAS in 11 of 12 cadavers.

CONCLUSIONS

Ultrasound-guided needle EMG of the EAS is convenient and accurate in cadavers and may be useful in clinical practice. Further studies comparing ultrasound-guided and landmark-guided needle EMG of the EAS in live patients will be needed.

Somatosensory stimulation treatments for postoperative analgesia of mixed hemorrhoids: Protocol for a systematic review and network meta-analysis

BACKGROUND

Pain after hemorrhoidal surgery bothers both clinicians and patients. Somatosensory stimulation treatments have shown promising effect on the pain after hemorrhoidal surgery, but the comparative effectiveness between them has not been studied. We aim to determine the relative effectiveness among these treatments on pain relief after hemorrhoidal surgery by using network meta-analysis.

METHOD

We will search the following electronic databases: MEDLINE, EMBASE, the Cochrane library, Chinese Biomedicine database (CBM), China National Knowledge Infrastructure (CNKI). We will include randomized controlled trials (RCTs) that examine the effect of somatosensory stimulation treatments on pain after hemorrhoidal surgery. The primary outcome will be the responder rate after treatment. The secondary outcomes will include the assessments with pain intensity scales (visual analog scale, numeric rating scale, or other scales) on day 1 to 7 after surgery. Two independent reviewers will extract needed information from eligible trials using standardized electronic forms. Network meta-analysis will be performed using a frequentist framework based on electrical network theory. The relative effectiveness of the treatments will be ranked by using P score, which is the mean probability of a treatment ranking the best in all treatments. Meta-regression will be performed to assess the impact of surgery type, anesthesia methods, and funding source on the treatment ranking. The quality of the eligible RCTs will be evaluated by the Cochrane risk of bias tool.

ETHICS AND DISSEMINATION

The result of this network meta-analysis will clarify which is the relatively best somatosensory-stimulation treatment in relieving postoperative pain caused by hemorrhoidal surgery, and the review will, therefore, guide the management of postoperative pain after hemorrhoidal surgery for clinicians and patients. This review does not require ethical approval and will be reported in a peer-reviewed journal.

TRIAL REGISTRATION NUMBER

PROSPERO CRD42018115558.

Pathophysiology of internal hemorrhoids

Hemorrhoidal disease is a fairly common and debilitating clinical entity. Despite centuries’ of attempts to shed light on its pathophysiology, to cure those affected and to improve sufferers’ quality of life, many aspects of the disease remain elusive. Individual beliefs and historical legends, accompanied by undocumented theories, have established and perpetuated the confusion regarding the mechanisms leading to the development of the disease and the rules governing its treatment. Hemorrhoids are classified as internal or external and are viewed as a disease when they become symptomatic. Returning to basic medical sciences, this mini-review focuses on internal hemorrhoids and aims to define the histology and anatomy of the normal and abnormal internal hemorrhoidal plexus and to encourage clinicians to comprehend the pathophysiology of the disease. If doctors can understand the pathophysiology of hemorrhoidal disease, they will be able to clarify the nature of the associated symptoms and complications and to make the correct therapeutic decision.

Polidocanol Foam Injected at High Doses with Intravenous Needle: The (Almost) Perfect Treatment of Symptomatic Internal Hemorrhoids

Background and Aims

Hemorrhoid disorders are common. This study aimed to assess the efficacy and safety of polidocanol foam injected at high doses with intravenous needle for the treatment of symptomatic internal hemorrhoids that prolapse or bleed.

Methods

We evaluated 2,000 consecutive patients with prolapsed hemorrhoids (grades II/III/IV) recruited over 6 years. Foam injection was performed in one to four sessions with polidocanol 2%: 10 mL of the mixture (2 mL liquid plus air) or 20 mL (4 mL liquid plus air). The number of sessions and amount of foam injected depended on initial hemorrhoid size, compliance to receive foam, and clinical response. The mixture, prepared using a three-way tap connected to two 10/20-mL syringes, was injected immediately after preparation using an intravenous needle. The primary endpoint was self-reported satisfaction without major complications at 4 weeks.

Results

Efficacy was very high, with 1,957 patients (98%) reporting satisfaction regarding blood loss control and prolapse reduction. The procedure was well tolerated: 1,838 patients (92%) presented mild/no pain. Objective reduction of prolapse volume was documented in 86% of reobserved cases. Complications were rare and usually minor: only 3 cases of clinically significant bleeding (0.15%), 2 of whom were on dual antiplatelet therapy plus oral anticoagulation, 2 cases of rectal abscess, 8 hemorrhoid thromboses, and 1 urinary retention requiring catheter (0.7% severe complications).

Conclusions

Treatment of internal hemorrhoids with polidocanol foam injected in high doses is very effective and safe for the control of blood loss and prolapse, even for patients on anticoagulation/antiplatelet treatment.

Management of Common Benign Anorectal Disease: What All Physicians Need to Know

Benign anorectal conditions produce anal pain, rectal bleeding, or discharge from the perianal region, which are highly prevalent symptoms in the general population. Hemorrhoidal disease, anal fissure, perianal abscess, proctalgia syndromes, and pruritus anii are the most common clinical disorders. Well-trained physicians, irrespective of their specialty, can treat most of these disorders and refer them to a specialist in proctology only when necessary. The aim of this review is to provide a practical guide to the management of benign anorectal disorders in terms of their initial management and the criteria for specialist referral.

A gastrointestinal stromal tumor with acute bleeding: Management and nursing

RATIONALE

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors involving the gastrointestinal tract. A small percentage of GISTs may cause acute gastrointestinal bleeding, which requires urgent surgical intervention.

PATIENT CONCERNS

In this case report, we present a 62-year-old male patient with who was hospitalized due to acute bleeding.

DIAGNOSES

The patient was diagnosed as GIST with low risk.

INTERVENTIONS

The patient was treated endoscopically with polidocanol sclerotherapy.

OUTCOMES

The mass was removed completely, and the patient was discharged at day 9 after operation.

LESSONS

This case indicates that GIST can present as massive upper gastrointestinal bleeding and urgent endoscopic sclerotherapy can be life-saving. The endoscopical intervention may be a good alternative for emergency.

The Clinical Efficacy of Infrared Photocoagulation Versus Closed Hemorrhoidectomy in Treatment of Hemorrhoid

Introduction: Infrared photocoagulation (IRC) was introduced as a mainstay procedure for treatment of hemorrhoids. The present study aimed to compare the clinical efficacy of IRC compared to closed hemorrhoidectomy. Methods: Forty patients suffering grade-3 hemorrhoid that referred to the surgery clinic at Imam Hossein hospital in Tehran in 2013 were randomly assigned to groups treated with the IRC modality or Ferguson's closed hemorrhoidectomy method. The patients in the 2 groups were followed-up for the first 24 hours after surgery and 8 weeks later. Postoperative pain was assessed using visual analogue scale (VAS) at three time points of 24 hours, 2 weeks and 8 weeks after operation. Results: Regarding bleeding, its overall prevalence was 5.0% in the IRC group and 30.0% in the hemorrhoidectomy group, which was significantly less prevalent in the IRC group. Notably, the IRC group had a lower mean postoperative pain score compared to the hemorrhoidectomy group. Time of return to work was significantly shorter in the IRC group; no difference was found in the mean duration of hospital stay, and recurrence rate across 2 groups. Conclusion: IRC procedure is safer than closed hemorrhoidectomy with lower postoperative pain severity, less secondary bleeding, and leads to earlier return to work in patients with hemorrhoid.

PPH AND BIOLOGICAL GLUE IN PATIENTS WITH HIGH RISK OF BLEEDING IN STAPLED HEMORRHOIDOPEXY

Background:

Stapled hemorrhoidopexy is a common treatment for grade 3 hemorrhoids. Patients with conditions that increase the risk of bleeding, as cardiac stents usage with clopidogrel bissulfate and liver cirrhosis, should receive an extra care in surgical procedures due to the high risk of bleeding. For this reason and for patients with third degree hemorrhoids we propose the use of stapled hemorrhoidopexy followed by the use of biological glue.

Aim:

Assess surgical outcomes in patients with hemorrhoids and high risk of bleeding submitted to stapled hemorrhoidopexy followed by biological glue.

Methods:

Between 2005 and 2015, 22 patients were analyzed, in a retrospective cohort study.

Results:

From 22 patients submitted to stapled hemorrhoidopexy followed by the use of biological glue, only one (4.5%) presented bleeding in the surgical postoperative. Patients do not have any other complications and pain in the postoperative period. The median (IQR) operation duration was 55 (12) min and the median (IQR) length of hospital stay after surgery was 3 (2) days.

Conclusion:

Patients with high risk of bleeding submitted to stapled hemorrhoidopexy followed by the use of biological glue presented very low rates of bleeding in the postoperative period.

Endothelin-1 and its receptors on haemorrhoidal tissue: a potential site for therapeutic intervention

BACKGROUND AND PURPOSE

Haemorrhoids is a common anorectal condition affecting millions worldwide. We have studied the effect of endothelin-1 (ET-1) and the role of endothelin ET_A and ET_B receptors in haemorrhoid tissue.

EXPERIMENTAL APPROACH

Protein expression of ET-1, ET_A and ET_B receptors were compared between haemorrhoids and normal rectal submucosa using Western blot analysis, with the localization of proteins determined by autoradiography and immunohistochemistry. Effects of ET-1 and sarafotoxin 6a on human colonic and rectal arteries and veins was assessed by wire myography and the involvement of receptor subtypes established by selective antagonists.

KEY RESULTS

Dense binding of [¹²⁵ I]-ET-1 to haemorrhoidal sections was reduced by selective receptor antagonists. A higher density of ET_B than ET_A receptors was found in haemorrhoidal, than in control rectal tissue and confirmed by Western blot analysis. ET_A and ET_B receptors were localized to smooth muscle of haemorrhoidal arteries and veins, with ET_B receptors on the endothelium. Human colonic and rectal arteries and veins were similarly sensitive to ET-1 and affected by the ET_A selective antagonist, but sarafotoxin S6a-induced contractions were more pronounced in veins and antagonized by a selective ET_B receptor antagonist.

CONCLUSIONS AND IMPLICATIONS

ET_A and ET_B receptors are present in human haemorrhoids with ET_B receptors predominating. ET_A receptors are activated by ET-1 to mediate a contraction in arteries and veins, but the latter are selectively activated by sarafotoxin S6a - a response that involves ET_B receptors at low concentrations. Selective ET_B agonists may have therapeutic potential to reduce congestion of the haemorrhoidal venous sinusoids.

The Use of Transanal Hemorrhoidal Dearterialization for Treatment of Hemorrhoid Disease at a Single Institution

Transanal hemorrhoidal dearterialization (THD) is a relatively new, minimally invasive approach for the treatment of hemorrhoid disease. Despite increasing use of this procedure, there remains scarce United States-based data on the perioperative variables affected by this surgical technique. This article details the experience with THD at a single institution. This is a single-institution study that includes consecutive patients that underwent THD at George Washington University from November 2011 to April 2014. After Institutional Review Board approval, retrospective chart review was performed. Patient demographic information, preoperative management of hemorrhoid disease, and quality of life indicators after THD were collected for all patients. A total of 96 patients underwent THD during the period of investigation. A majority of the patients were male and all patients had grade II or III hemorrhoids. Most patients who underwent THD presented with rectal bleeding. Four patients required postoperative admission to the hospital for pain control, eight patients experienced constipation postoperatively, and one patient had recurrence of their hemorrhoid disease at 30-day follow-up. No patients required admission to the hospital for postoperative hemorrhage and none experienced urinary retention or incontinence of flatus or stool. THD is a feasible alternative to Ferguson hemorrhoidectomy for the surgical treatment of grade II and III hemorrhoidal disease. Future prospective studies are needed to help improve patient selection for each respective surgical approach.

A Randomized Controlled Trial Comparing Suture-Fixation Mucopexy and Doppler-Guided Hemorrhoidal Artery Ligation in Patients with Grade III Hemorrhoids

Background. We aimed to evaluate the effectiveness of a suture-fixation mucopexy procedure by comparing with Doppler-guided hemorrhoidal artery ligation (DGHAL) in the management of patients with grade III hemorrhoids. Methods. This was a randomized controlled trial. One hundred patients with grade III hemorrhoids were randomly assigned to receive suture-fixation mucopexy (n = 50) or DGHAL (n = 50). Outcome assessments were performed at 2 weeks, 12 months, and 24 months. Assessments included resolution of clinical symptoms, postoperative complications, duration of hospitalization, and total costs. Results. At 2 weeks, one (2%) patient in suture-fixation group and four (8%) patients in DGHAL group had persistent prolapsing hemorrhoids. Postoperative bleeding was observed in two patients (4%) in suture-fixation group and one patient in DGHAL group. There was no significant difference in short-term recurrence between groups. Postoperative complications and duration of hospitalization were comparable between the two groups. Rates of recurrence of prolapse or bleeding at 12 months did not differ between groups. However, recurrence of prolapse at 24 months was significantly more common in DGHAL group (19.0% versus 2.3%, p = 0.030). Conclusions. Compared with DGHAL, the suture-fixation mucopexy technique had comparable short-term outcomes and favorable long-term outcomes.

An Assessment of Margins after Lumpectomy in Breast Cancer Management

We performed this study to evaluate our indications for margin re-excision (MRE) in the management of cancer patients opting for breast conservation therapy (BCT). We identified patients choosing breast conservation therapy from January 2012 to May 2014. Margins were considered negative if >2 mm, close if <2 mm, and positive if ink was detected abutting tumor. Patients with close and positive margins underwent MRE. We identified 247 patients of which 190 had negative margins and did not require MRE, 46 patients had a close margin, and 11 had a positive margin, leading to an MRE rate of 23 per cent (57 of 247). The following variables were evaluated: tumor size, stage, estrogen receptor, progesterone receptor, HER2/neu receptor, and node status. None predicted the presence of tumor in the MRE specimen ( P > 0.05). Patients with close margins had a 6.5 per cent (3 of 46), and patients with positive margins had a 36.4 per cent (4 of 11) incidence of tumor in the MRE specimens; this difference was statistically significant ( P = 0.02). The low rate of finding tumor in MRE specimens of patients with close margins after lumpectomy for breast carcinoma argues for limiting MRE to patients with positive margins (ink on tumor) only. We have adopted this approach in our institution.

Cap-assisted endoscopic sclerotherapy for hemorrhoids: Methods, feasibility and efficacy

AIM: To evaluate the methodology, feasibility, safety and efficacy of a novel method called cap-assisted endoscopic sclerotherapy (CAES) for internal hemorrhoids.

METHODS: A pilot study on CAES for grade I to III internal hemorrhoids was performed. Colon and terminal ileum examination by colonoscopy was performed for all patients before starting CAES. Polypectomy and excision of anal papilla fibroma were performed if polyps or anal papilla fibroma were found and assessed to be suitable for resection under endoscopy. CAES was performed based on the requirement of the cap, endoscope, disposable endoscopic long injection needle, enough insufflated air and sclerosing agent.

RESULTS: A total of 30 patients with grade I to III internal hemorrhoids was included. The follow-up was more than four weeks. No bleeding was observed after CAES. One (3.33%) patient claimed mild tenesmus within four days after CAES in that an endoscopist performed this procedure for the first time. One hundred percent of patients were satisfied with this novel procedure, especially for those patients who underwent CAES in conjunction with polypectomy or excision of anal papilla fibroma.

CONCLUSION: CAES as a novel endoscopic sclerotherapy should be a convenient, safe and effective flexible endoscopic therapy for internal hemorrhoids.

Treatment of Internal Hemorrhoids by Endoscopic Sclerotherapy with Aluminum Potassium Sulfate and Tannic Acid

Objective. A new sclerosing agent for hemorrhoids, aluminum potassium sulfate and tannic acid (ALTA), is attracting attention as a curative treatment for internal hemorrhoids without resection. The outcome and safety of ALTA sclerotherapy using an endoscope were investigated in the present study. Materials and Methods. Subjects comprised 83 internal hemorrhoid patients (61 males and 22 females). An endoscope was inserted and retroflexed in the rectum, and a 1st-step injection was applied to the upper parts of the hemorrhoids. The retroflexed scope was returned to the normal position, and 2nd–4th-step injections were applied to the middle and lower parts of the hemorrhoids under direct vision. The effects of endoscopic ALTA sclerotherapy were determined by evaluating the condition of the hemorrhoids using an anoscope and interviewing the patient 28 days after the treatment. Results. A cure, improvement, and failure were observed in 54 (65.1%), 27 (32.5%), and 2 (2.4%) patients, respectively, treated with ALTA. Complications developed in 4 patients (mild fever in 3 and hematuria in 1). Recurrence occurred in 9.6%. Conclusions. The results of the present study suggest that endoscopic ALTA has the potential to become a useful and minimally invasive approach for ALTA sclerotherapy.

A prospective, randomized, three arm, open label study comparing the safety and efficacy of PP110, a novel treatment for hemorrhoids to preparation-H® maximum strength cream in the treatment of grade 2-3 hemorrhoids

BACKGROUND

Hemorrhoids are a common disorder that affects the quality of life of millions of people worldwide. The effectiveness of OTC medication is limited and they mainly provide symptomatic relief. In order to treat this ailment, we formulated PP110 Gel and Wipes, as a novel treatment for hemorrhoids. PP110 is based on known active ingredients with a topical film-forming agent designed to provide physical protection and prolonged tissue contact with the active ingredients.

METHODS

PP110 Gel, PP110 Wipes and the comparator Preparation-H® were used on three patient cohorts. Treatment was administered once daily for PP110, and three-four times daily for Preparation-H®, for 14 days. Six different clinical parameters relating to common symptoms of hemorrhoids were monitored.

RESULTS

PP110 Gel was significantly better than Preparation-H® in reducing bleeding (Δ = 6 %), providing pain relief (Δ = 10 %) and controlling itching (Δ = 11 %). These three parameters are considered as the most common distressing symptoms for hemorrhoids patients, demonstrating that PP110 is superior to conventional treatment.

CONCLUSION

This study demonstrated the efficacy of the PP110 Gel in treating hemorrhoids and its superiority to conventional treatments. The PP110 film-based formulation provides a slow-release mechanism and as a consequence, a prolonged therapeutic window. PP110 was both more effective in reducing hemorrhoids symptoms and more convenient to use, in that it only required application once per day.

A prospective, randomized, three arm, open label study comparing the safety and efficacy of PP110, a novel treatment for hemorrhoids to preparation-H® maximum strength cream in the treatment of grade 2-3 hemorrhoids

Background

Hemorrhoids are a common disorder that affects the quality of life of millions of people worldwide. The effectiveness of OTC medication is limited and they mainly provide symptomatic relief. In order to treat this ailment, we formulated PP110 Gel and Wipes, as a novel treatment for hemorrhoids. PP110 is based on known active ingredients with a topical film-forming agent designed to provide physical protection and prolonged tissue contact with the active ingredients.

Methods

PP110 Gel, PP110 Wipes and the comparator Preparation-H® were used on three patient cohorts. Treatment was administered once daily for PP110, and three-four times daily for Preparation-H®, for 14 days. Six different clinical parameters relating to common symptoms of hemorrhoids were monitored.

Results

PP110 Gel was significantly better than Preparation-H® in reducing bleeding (Δ = 6 %), providing pain relief (Δ = 10 %) and controlling itching (Δ = 11 %). These three parameters are considered as the most common distressing symptoms for hemorrhoids patients, demonstrating that PP110 is superior to conventional treatment.

Conclusion

This study demonstrated the efficacy of the PP110 Gel in treating hemorrhoids and its superiority to conventional treatments. The PP110 film-based formulation provides a slow-release mechanism and as a consequence, a prolonged therapeutic window. PP110 was both more effective in reducing hemorrhoids symptoms and more convenient to use, in that it only required application once per day.

Recombinant streptokinase vs hydrocortisone suppositories in acute hemorrhoids: A randomized controlled trial

AIM: To compare the efficacy and safety of recombinant streptokinase (rSK) vs hydrocortisone acetate-based suppositories in acute hemorrhoidal disease.

METHODS: A multicenter (11 sites), randomized (1:1:1), open, controlled trial with parallel groups was performed. All participating patients gave their written, informed consent. After inclusion, patients with acute symptoms of hemorrhoids were centrally randomized to receive, as outpatients, by the rectal route, suppositories of rSK 200000 IU of one unit every 8 h (first 3 units) and afterwards every 12 h until 8 administrations were completed (schedule A), one unit every 8 h until 6 units were completed (schedule B), or 25 mg hydrocortisone acetate once every 8 h up to a maximum of 24 administrations. Evaluations were performed at 3, 5, and 10 d post-inclusion. The main end-point was the 5^th-day response (disappearance of pain and bleeding, and ≥ 70% reduction of the lesion size). Time to response and need for thrombectomy were secondary efficacy variables. Adverse events were also evaluated.

RESULTS: Groups were homogeneous with regards to demographic and baseline characteristics. Fifth day complete response rates were 156/170 (91.8%; 95%CI: 87.3-96.2), 155/170 (91.2%; 95%CI: 86.6%-95.7%), and 46/170 (27.1%; 95%CI: 20.1%-34.0%) with rSK (schedule A and B) and hydrocortisone acetate suppositories, respectively. These 64.6% and 63.9% differences (95%CI: 56.7%-72.2% and 55.7%-72.0%) were highly significant (P < 0.001). This advantage was detected since the early 3^rd day evaluation (68.8% and 64.1% vs 7.1% for the rSK and active control groups, respectively; P < 0.001) and was maintained even at the late 10^th day assessment (97.1% and 93.5% vs 67.1% for rSK and hydrocortisone acetate, respectively; P < 0.001). Time to response was 3 d (95%CI: 2.9-3.1) for both rSK groups and 10 d (95%CI: 9.3-10.7) in the hydrocortisone acetate group. This difference was highly significant (P < 0.001). All subgroup stratified analyses (with or without thrombosis and hemorrhoid classification) showed a statistically significant advantage for the rSK groups. Thrombectomy was necessary in 4/251 and 14/133 patients with baseline thrombosis in the rSK and hydrocortisone acetate groups, respectively (P < 0.001). There were no adverse events attributable to the experimental treatment.

CONCLUSION: rSK suppositories showed a significant advantage over a widely-used over-the-counter hydrocortisone acetate preparation for the treatment of acute hemorrhoidal illness, as well as having an adequate safety profile.

Identifying the variables associated with pain during transrectal ultrasonography of the prostate

OBJECTIVE

The purpose of this study was to prospectively investigate the degree of pain experienced by the patients receiving transrectal ultrasonography (TRUS) of the prostate by applying a visual analog scale. We also identified the clinical parameters influencing pain during the TRUS examination.

MATERIALS AND METHODS

Records were obtained from a prospective database for male patients who received TRUS of prostate in the outpatient department of Chang Gung Memorial Hospital, Taiwan, from January 2014 to June 2014. The patients underwent a detailed physical examination and medical history review. Immediately after the TRUS examination, the patients completed questionnaires based on a ten-point visual analog pain scale. The variables of interest were age, body mass index, prostate volume, prostate sagittal length, prostate-specific antigen, previous TRUS experience, external hemorrhoids, anal surgical history, prostate calcification, and image artifact caused by stool in the rectum. All variables were correlated to the visual analog scale by applying multivariate regression analysis.

RESULTS

By using linear regression analysis, we identified the independent factors that affected the pain score during the TRUS examination. The patients who received the examination for the first time or had longer prostate sagittal lengths, external hemorrhoids, anal surgical history, or stool stored in the rectum experienced more pain during the TRUS examination. Furthermore, the pain was reduced when we provided the patients with a detailed explanation before the procedure and allowed them to observe the real-time images during the examination.

CONCLUSION

Although a TRUS examination is uncomfortable for patients, after having identified the factors affecting pain, physicians can assist patients in reducing pain during the procedure, thus providing higher quality examinations.