Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium

Haemorrhoidal disease in pregnancy: results from a self-assessment questionnaire administered by means of a social network

BACKGROUND

The anal symptoms occurring during pregnancy and post-partum, mainly related to Haemorrhoidal Disease (HD), have been reported with in a wide range of incidence in the literature. Although in many cases the course of the disease is mild and self-limiting, sometimes it is severe enough to affect quality of life.

METHODS

Our study has been conducted through a questionnaire administered via social media with the aim of obtaining epidemiologic data on the incidence of the symptoms of HD in an unselected population of pregnant women. In addition, we looked for the presence of those factors notoriously predisposing or associated to HD (constipation, straining on the toilet, low dietary fibres and fluid intake).

RESULTS

Out of 133 patients 51% reported symptoms of HD during pregnancy, mainly in the second and third trimester. Constipation, straining on the toilet, low dietary fibres and fluid intake were not significantly related to incidence of HD. Only a previous history of HD was correlated to onset of symptoms of HD in pregnancy and reached a statistical significance (odds ratio = 5.2, p < 0.001).

CONCLUSION

Although with the limitations posed by the nature of our retrospective study via a self-assessment interview, our results suggest that the occurrence of HD in pregnancy seems not sustained by the classical risk factors observed in the general population. At the moment, specific therapeutic measures are lacking and treatment relies on empiric suggestions concerning diet, fluid intake, bowel care, local ointment. Further studies are needed in order to identify a targeted etiologic treatment.

Haemorrhoids and Anal Fissures in Pregnancy: Predictive Factors and Effective Treatments

Introduction Haemorrhoids and anal fissures (HAF) are common in pregnancy and can severely affect the quality of life of those suffering from them. Despite the condition being common, there is limited evidence, formal guidelines or recommendations on treatment, and little is known about the natural course during pregnancy. Methods This was a prospective, observational cohort study conducted at a tertiary-referral university maternity hospital (The National Maternity Hospital, Dublin), conducted over a nine-month period. The first part of the study was a case-control study of antenatal patients over 34 weeks' gestation. The second part of the study involved a cohort of postnatal patients. Anonymous patient surveys were performed and analysed. Results Two hundred and fifty-eight patients were recruited into the study from the outpatient clinics and wards of one maternity hospital from April to December 2021. Of the antenatal patients, 82/184 (45%) of these patients had symptoms of HAF and 102/184 (55%) antenatal patients were unaffected, acting as controls. In addition, 74 affected postnatal patients were also included. In the affected antenatal group, 36/82 (44%) of patients had self-reported HAF (symptoms or signs of HAF); 50/82 (61%) of patients diagnosed with HAF on their own. 12/82 (15%) noticed symptoms in the first trimester, 25/82 (30%) in the second and 45/82 (55%) in the third. 142/184 (77%) of antenatal patients used conservative methods to manage their symptoms, including an increase in dietary fibre. 144/184 (78%) used medical treatments including suppositories. Only one patient had surgery. 70/156 (45%) of postnatal patients' symptoms resolved within days, 42/156 (27%) in weeks and 44/156 (28%) within months. Conclusion HAF affect almost half of the pregnancies. Age over 35 was significantly associated with antenatal haemorrhoids or anal fissures. Concerningly, the majority of patients (64%) self-diagnose and manage the condition without either seeking or receiving guidance from medical professionals. In terms of the natural course of the disease, it was encouraging that 45% of patients' symptoms resolved within a few days. This will help when counselling patients with distressing symptoms. Conservative measures such as increased dietary fibre, increased fluid intake and bath salts were effective in relieving symptoms for the majority of patients.

Recurrence Rates and Pharmacological Treatment for Hemorrhoidal Disease: A Systematic Review

INTRODUCTION

Hemorrhoidal disease (HD) is characterized by prolapse of the inflamed and bleeding vascular tissues of the anal canal. Although HD is associated with a high recurrence rate, there is a lack of understanding around interventions that can reduce recurrence and improve outcomes for patients. As such, a systematic literature review (SLR) was conducted to summarize evidence on epidemiology, recurrence, and efficacy of interventions in HD.

METHODS

Real-world evidence (RWE) studies evaluating the incidence, prevalence, or recurrence of HD, as well as SLRs including a meta-analytic component reporting on the efficacy of systemic or topical pharmacological treatments for adults with HD, were included. Systematic searches were conducted in MEDLINE, Embase, Cumulative Index to Nursing and Allied Health Literature, and the Cochrane Database of Systematic Reviews.

RESULTS

The SLR identified 44 eligible publications. Consistent data were limited on the epidemiology of HD or HD recurrence. Specifically, incidence and prevalence reported across geographies were impacted by differences in data collection. Reported risk factors for HD were sedentary behavior, constipation, male gender, and age. Twenty-three RWE studies and one meta-analysis reported HD recurrence rates ranging from 0 to 56.5% following surgery or phlebotonics, with most (n = 19) reporting rates of 20% or less. In addition to time since treatment, risk factors for recurring disease were similar to those for HD in general. With respect to treatment, micronized purified flavonoid fractions significantly improved the main symptoms of HD compared to other pharmacological treatments.

CONCLUSION

The SLRs did not identify any RWE studies reporting recurrence in patients receiving systemic or topical treatments, highlighting the need for future research in this area. Further, more studies are needed to understand the optimum duration of medical treatment to prevent recurrence.

Perianal Diseases in Pregnancy and After Childbirth: Frequency, Risk Factors, Impact on Women's Quality of Life and Treatment Methods

Hemorrhoids and anal fissures occur in about 40% of pregnant women and women during postpartum period. Usually they occur during the third trimester of pregnancy and 1–2 days after giving birth. Constipation during pregnancy, perianal diseases during previous pregnancy and childbirth, instrumental delivery, straining duration of more than 20 min, and weight of the newborn more than 3,800 g are associated with hemorrhoids. Perianal diseases reduce the quality of life of both pregnant and postpartum women. In the absence of acute conditions, surgical treatment of hemorrhoids is delayed after pregnancy, childbirth, and lactation. Thrombosed internal hemorrhoids and perianal thrombosis are to be treated conservatively in most instances by prescribing adequate pain relief, oral, and topical flavonoid preparations.

Evaluation of the Efficacy and Safety of a Compound of Micronized Flavonoids in Combination With Vitamin C and Extracts of Centella asiatica, Vaccinium myrtillus, and Vitis vinifera for the Reduction of Hemorrhoidal Symptoms in Patients With Grade II and III Hemorrhoidal Disease: A Retrospective Real-Life Study

Background and Aim: Several evidences have shown how, in hemorrhoidal disease, phlebotonic flavonoid agents such as quercetin reduce capillary permeability by increasing vascular walls resistance, how rutin and vitamin C have antioxidant properties, and that Centella asiatica has reparative properties towards the connective tissue. A retrospective study was designed in order to evaluate the efficacy and safety of a compound consisting of micronized flavonoids in combination with vitamin C and extracts of C. asiatica, Vaccinium myrtillus, and Vitis vinifera for grade II and III hemorrhoidal disease.

Patients and Methods: Data of 49 patients, over 18, who were following a free diet regimen, not on therapy with other anti-hemorrhoid agents, treated with a compound consisting of 450 mg of micronized diosmin, 300 mg of C. asiatica, 270 mg of micronized hesperidin, 200 mg of V. vinifera, 160 mg of vitamin C, 160 mg of V. myrtillus, 140 mg of micronized quercetin, and 130 mg of micronized rutin (1 sachet or 2 tablets a day) for 7 days were collected. Hemorrhoid grade according to Goligher’s scale together with anorectal symptoms (edema, prolapse, itching, thrombosis, burning, pain, tenesmus, and bleeding) both before treatment (T0) and after 7 days of therapy (T7) were collected. Primary outcomes were the reduction of at least one degree of hemorrhoids according to Goligher’s scale assessed by proctological examination and compound safety. The secondary outcome was the reduction of anorectal symptoms assessed by questionnaires administered to patients.

Results: Forty-four patients (89.8%) presented a reduction in hemorrhoidal grade of at least one grade (p < 0.001). No adverse events with the use of the compound were noted. A significant reduction was observed in all anorectal symptoms evaluated (p < 0.05). No predictors of response to the compound were identified among the clinical and demographic variables collected.

Conclusion: The compound analyzed was effective and safe for patients with grade II and III hemorrhoidal disease according to Goligher’s scale.

Review of Evidence for Environmental Causes of Uveal Coloboma

Uveal coloboma is a condition defined by missing ocular tissues and is a significant cause of childhood blindness. It occurs from a failure of the optic fissure to close during embryonic development,and may lead to missing parts of the iris, ciliary body, retina, choroid, and optic nerve. Because there is no treatment for coloboma, efforts have focused on prevention. While several genetic causes of coloboma have been identified, little definitive research exists regarding the environmental causes of this condition. We review the current literature on environmental factors associated with coloboma in an effort to guide future research and preventative counseling related to this condition.

A Prospective Study on the Efficacy of Two Different Phlebotonic Therapies as a Bridge to Surgery in Patients with Advanced Hemorrhoidal Disease

The aims of this study were to evaluate the efficacy of two different phlebotonic therapies, preoperatively administered in advanced hemorrhoidal disease (HD) patients with recommendation for surgery, and to assess patient satisfaction after treatment. In this prospective observational study, 100 patients were preoperatively treated either with micronized purified flavonoid fraction (group A) or sublingual nano-emulsion flavonoid (group B). HD symptoms, local inflammation signs and patients' satisfaction were evaluated at baseline visit (T0), after 4 weeks of therapy (T1) and 8 weeks after its discontinuation (T2). In group A, a significant improvement for all HD symptoms and inflammation signs was observed after therapy (T1), followed by a reduction of efficacy in T2, except for itching and edema. In group B, therapy had a significant benefit on symptoms and local inflammation at T1, which persisted after its discontinuation for all symptoms, and edematous hemorrhoids. In both groups, the satisfaction rate was "good" in 60% of patients and patients were statistically significant more satisfied at T1 compared with T2 (p = 0.0001). No adverse events were recorded. Preoperative treatment was safe and useful to optimize patients' clinical condition prior to surgery.

Consensus statement of the Italian society of colorectal surgery (SICCR): management and treatment of hemorrhoidal disease

Hemorrhoidal disease (HD) is the most common proctological disease in the Western countries. However, its real prevalence is underestimated due to the frequent self-medication.The aim of this consensus statement is to provide evidence-based data to allow an individualized and appropriate management and treatment of HD. The strategy used to search for evidence was based on application of electronic sources such as MEDLINE, PubMed, Cochrane Review Library, CINAHL, and EMBASE.These guidelines are inclusive and not prescriptive.The recommendations were defined and graded based on the current levels of evidence and in accordance with the criteria adopted by American College of Chest Physicians. The recommendations were graded A, B, and C.

Hemorrhoid management in women: the role of tribenoside + lidocaine

Hemorrhoids are commonly reported in women. However, despite the high prevalence of hemorrhoids in women and the major impact of this condition on quality of life, specific evidence and recommendations on the treatment of hemorrhoids in women are scant. This paper reviews various options in current therapy for hemorrhoids in women—namely, medical intervention (topical and systemic drug therapy)—and discusses the available clinical evidence for an appropriate use of over-the-counter topical formulations for the symptomatic treatment of hemorrhoids. Its focus is on a medical preparation containing tribenoside + lidocaine, available as a rectal cream (tribenoside 5%/lidocaine 2%) and a suppository (tribenoside 400 mg/lidocaine 40 mg) and marketed under the brand Procto-Glyvenol^® (Recordati, SpA, Italy). Given its rapid comprehensive efficacy on all the different symptoms of hemorrhoids, the tribenoside + lidocaine combination can find a place in the treatment of this hemorrhoidal disease. Importantly, its efficacy and tolerability have been formally evaluated in several well-conducted studies, some of which were specifically conducted in women. In particular, tribenoside + lidocaine can be safely administered in postpartum women and in pregnant women after the first trimester of pregnancy. In pregnant women, the tribenoside/lidocaine combination significantly improved both subjective and objective symptoms of hemorrhoids. Fast onset of symptom relief was reported from 10 minutes after administration, lasting up to 10–12 hours. On these bases, tribenoside + lidocaine can represent a fast, effective, and safe option to treat hemorrhoids when conservative therapy is indicated, and it deserves consideration as a first-line treatment of this disease in clinical practice.

Japanese Practice Guidelines for Anal Disorders I. Hemorrhoids

The pathogenesis of hemorrhoids is a weakening of the anal cushion and spasm of the internal sphincter. Bowel habits and lifestyles can be risk factors for hemorrhoids. The prevalence of hemorrhoids can encompass 4 to 55% of the population. Symptoms include bleeding, pain, prolapsing, swelling, itching, and mucus soiling. The diagnosis of hemorrhoids requires taking a thorough history and conducting an anorectal examination. Goligher's classification, which indicates the degree of prolapsing with internal hemorrhoids, is useful for choosing treatment. Drug therapy for hemorrhoids is typically utilized for bleeding, pain, and swelling. Ligation and excision (LE) is considered for Grade III and IV internal and external hemorrhoids. Rubber band ligation is used to treat up to Grade III internal hemorrhoids. Phenol almond oil is effective for internal hemorrhoids up to Grade III, while aluminum potassium sulfate and tannic acid have shown efficacy in treating prolapsing in internal hemorrhoids at Grades II, III, and IV. Procedure for prolapse and hemorrhoids (PPH) is surgically effective for Grade III internal hemorrhoids; however, the long-term prognosis is not favorable, with high recurrence rates. Separating ligation is effective surgical treatment for internal/external hemorrhoids Grade III and Grade IV. The basic approach to thrombosed external hemorrhoids and incarcerated hemorrhoids is conservative treatment; however, in some acute or severe cases, surgical resection is considered. Comparing the different instruments used for hemorrhoid surgery, all reduce operating time, blood loss, post-operative pain, and length of time until the return to normal activity. They do, of course, increase the cost of the procedure.

Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement

Hemorrhoids are one of the most common medical and surgical diseases and the main reason for a visit to a coloproctologist. This consensus statement was drawn up by the Italian society of colorectal surgery in order to provide practice parameters for an accurate assessment of the disease and consequent appropriate treatment. The authors made a careful search in the main databases (MEDLINE, PubMed, Embase and Cochrane), and all results were classified on the basis of the grade of recommendation (A-C) of the American College of Chest Physicians.

Pregnancy and postpartum bowel changes: constipation and fecal incontinence

Pregnancy and the postpartum period are often associated with many gastrointestinal complaints, including nausea, vomiting, and heartburn; however, the most troublesome complaints in some women are defecatory disorders such as constipation and fecal incontinence, especially postpartum. These disorders are often multifactorial in etiology, and many studies have looked to see what risk factors lead to these complications. This review discusses the current knowledge of pelvic floor and anorectal physiology, especially during pregnancy, and reviews the current literature on causes and treatments of postpartum bowel symptoms of constipation and fecal incontinence.

Evidências sobre tratamentos clínicos conservadores para doença hemorroidária

Objetivo: o objetivo desta avaliação de tecnologia em saúde foi analisar as evidências sobre tratamentos clínicos conservadores para doença hemorroidária utilizáveis na Atenção Primária à Saúde. Métodos: buscou-se no Embase, LILACS e MEDLINE via Pubmed por meta-análises, revisões sistemáticas e ensaios clínicos controlados e aleatorizados, publicados até dezembro de 2012, sem limite de linguagem. Os estudos deveriam avaliar os efeitos dos tratamentos clínicos conservadores (fibras ou laxantes, flavonoides, analgésicos, corticosteroides, banhos de assento ou pomadas de nitroglicerina) comparados a placebo ou entre si. Os desfechos considerados foram: melhora global dos sintomas, sangramento, prurido, dor, prolapso e efeitos adversos. Resultados: uma meta-análise demonstrou que fibras promovem melhora global dos sintomas e do sangramento e diminuem a recorrência após procedimentos ambulatoriais. Três meta-análises mostraram a eficácia de flavonoides para sangramento agudo e pós-operatório, melhora global dos sintomas, exsudação perianal e recorrência após episódio agudo. Não houve diferença estatística para prurido, dor, prolapso ou efeitos adversos nos dois casos. Flavonoides do tipo rutosídeos reduziram sintomas em gestantes, apesar da insuficiência dos dados para comprovar sua segurança. Não foram encontrados estudos que preenchessem os critérios de seleção para os demais tipos de tratamento. Conclusões: fibras ou flavonoides orais podem ser utilizados na atenção primária para a melhora global dos sintomas e sangramento na doença hemorroidária graus I e II; para paciente grau III que não deseje se submeter a procedimento ambulatorial; e no pós-operatório. Ensaios clínicos controlados e aleatorizados com qualidade metodológica adequada são necessários para confirmar estes resultados.

Conservative and surgical treatment of haemorrhoids

The management of haemorrhoids has evolved rapidly during the past few decades. Several new treatments have been proposed with the aim of reducing patients' postoperative pain, time to return to normal life, risk of early and late complications, and recurrence rate. Although conservative treatment based on dietary and lifestyle changes can help the majority of patients, and rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids, surgery is required for the most advanced stages. Milligan-Morgan haemorrhoidectomy is considered to be the gold-standard approach for grade IV haemorrhoids. An increasing number of minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, have now been proposed for the management of grade III haemorrhoids. These approaches aim to correct the underlying pathophysiological mechanisms involved in the aetiology of haemorrhoids. An increased risk of recurrence is the price to pay for these minimally invasive and less painful treatments, but the sparing of the sensitive anoderm and a rapid return to normal life without pain are greatly appreciated by patients. An algorithm for the management of haemorrhoids using evidence-based medicine is also presented here.

[Consensus statement haemorrhoidal disease]

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Anorectal symptoms during pregnancy: how important is trimester?

PURPOSE

The frequency of anorectal symptoms amongst pregnant women has not been objectively investigated in the United Kingdom. The aim of this study was to determine the frequency of anorectal symptoms during each trimester of pregnancy.

METHODS

Women attending the antenatal clinics at a London teaching hospital were asked to complete a questionnaire. The presence or absence of common anorectal symptoms experienced both before and during the current pregnancy together with demographic and pregnancy data was collected. Statistical analysis was performed using Fisher's exact test.

RESULTS

Two hundred seventeen patients (first trimester n=75, second trimester n=70 and third trimester n=72) participated. A significant increase in the frequency of symptoms was observed in the third (43.1%) compared to the first (16.0%, p<0.001) and second (22.9%, p=0.013) trimesters. The incidence of per rectal bleeding was significantly greater in the third trimester (30.6%) compared to the first (10.6%, p=0.004) and the second (12.9%, p=0.014) trimesters. Similarly, anal pain was significantly more frequent in the third trimester (34.7%) compared to the first (13.3%, p=0.003) and the second (12.9%, p=0.003) trimesters.

CONCLUSION

The frequency of anorectal symptom reporting appears to increase as pregnancy progresses. Further investigation and research is warranted to determine the configuration of services that may be required to treat those affected.

Hemorrhoids in pregnancy

QUESTION

One of my patients is in the third trimester of her first pregnancy. She has recently experienced spotting during her bowel movements. She has hemorrhoids. What medications are safe?

ANSWER

The treatment is mainly symptomatic for most patients. Most forms of the condition can be treated by increasing fibre content in the diet, administering stool softeners, increasing liquid intake, and training in toilet habits. Although none of the topical antihemorrhoidal agents commonly used have been assessed for safety in pregnancy, it is unlikely that the constituent parts (anesthetic, corticosteroids, and anti-inflammatory agents) will harm the third-trimester infant. In most women, most symptoms of the condition will resolve spontaneously soon after giving birth.

A review of the methodological features of systematic reviews in maternal medicine

BACKGROUND

In maternal medicine, research evidence is scattered making it difficult to access information for clinical decision making. Systematic reviews of good methodological quality are essential to provide valid inferences and to produce usable evidence summaries to guide management. This review assesses the methodological features of existing systematic reviews in maternal medicine, comparing Cochrane and non-Cochrane reviews in maternal medicine.

METHODS

Medline, Embase, Database of Reviews of Effectiveness (DARE) and Cochrane Database of Systematic Reviews (CDSR) were searched for relevant reviews published between 2001 and 2006. We selected those reviews in which a minimum of two databases were searched and the primary outcome was related to the maternal condition. The selected reviews were assessed for information on framing of question, literature search and methods of review.

RESULTS

Out of 2846 citations, 68 reviews were selected. Among these, 39 (57%) were Cochrane reviews. Most of the reviews (50/68, 74%) evaluated therapeutic interventions. Overall, 54/68 (79%) addressed a focussed question. Although 64/68 (94%) reviews had a detailed search description, only 17/68 (25%) searched without language restriction. 32/68 (47%) attempted to include unpublished data and 11/68 (16%) assessed for the risk of missing studies quantitatively. The reviews had deficiencies in the assessment of validity of studies and exploration for heterogeneity. When compared to Cochrane reviews, other reviews were significantly inferior in specifying questions (OR 20.3, 95% CI 1.1-381.3, p = 0.04), framing focussed questions (OR 30.9, 95% CI 3.7- 256.2, p = 0.001), use of unpublished data (OR 5.6, 95% CI 1.9-16.4, p = 0.002), assessment for heterogeneity (OR 38.1, 95%CI 2.1, 688.2, p = 0.01) and use of meta-analyses (OR 3.7, 95% CI 1.3-10.8, p = 0.02).

CONCLUSION

This study identifies areas which have a strong influence on maternal morbidity and mortality but lack good quality systematic reviews. Overall quality of the existing systematic reviews was variable. Cochrane reviews were of better quality as compared to other reviews. There is a need for good quality systematic reviews to inform practice in maternal medicine.