Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study

Natural Products with Potential Effects on Hemorrhoids: A Review

Hemorrhoid disease is a common anorectal disorder affecting populations worldwide, with high prevalence, treatment difficulties, and considerable treatment costs. Compared to other treatment options, medical therapy for hemorrhoids offers minimal harm, more dignity to patients, and is more economical. Unfortunately, there are few chemical hemorrhoid medications available clinically, which makes the search for efficacious, cost-effective, and environmentally friendly new medication classes a focal point of research. In this context, searching for available natural products to improve hemorrhoids exhibits tremendous potential. These products are derived from nature, predominantly from plants, with a minor portion coming from animals, fungi, and algae. They have excellent coagulation pathway regulation, anti-inflammatory, antibacterial, and tissue regeneration activities. Therefore, we take the view that they are a class of potential hemorrhoid drugs, prevention products, and medication add-on ingredients. This article first reviews the factors contributing to the development of hemorrhoids, types, primary symptoms, and the mechanisms of natural products for hemorrhoids. Building on this foundation, we screened natural products with potential hemorrhoid improvement activity, including polyphenols and flavonoids, terpenes, polysaccharides, and other types.

Precision and Power: A Comprehensive Review of Exploring the Role of Laser Treatment in Hemorrhoidal Management

Hemorrhoids are a prevalent condition that significantly impacts the quality of life of affected individuals. Traditional treatment modalities range from conservative management to invasive surgical procedures, each with varying degrees of effectiveness and patient burden. Recently, laser treatment has emerged as a promising alternative, offering a minimally invasive approach with the potential for reduced complications and faster recovery. This comprehensive review aims to evaluate the role of laser treatment in hemorrhoidal management, exploring its mechanisms, clinical outcomes, safety, and economic implications. Through an extensive literature review and analysis of clinical trials, this paper assesses the efficacy of laser therapy compared to conventional treatments, highlighting its advantages in pain reduction, healing times, and patient satisfaction. The review also discusses the different types of lasers, including diode and Nd:YAG, and their specific applications in hemorrhoidal treatment. The findings indicate that laser treatment can be an effective and safe option for patients, encouraging its consideration as part of standard hemorrhoidal care protocols. However, gaps in long-term outcome data and the need for further studies on cost-effectiveness are identified. The review concludes with recommendations for future research, the advancement of laser technology, and the potential integration of laser treatment into clinical practice, aiming to enhance patient outcomes in hemorrhoidal management.

Prevalence, Characteristics, and Treatment of Hemorrhoids During Pregnancy: A Nationwide Population-Based Cohort Study in Taiwan

Background: Hemorrhoids, a gastrointestinal tract disorder, are common during pregnancy. However, large-scale epidemiological studies on hemorrhoids during pregnancy are limited. Therefore, this study used analyzed data from a nationwide population-based database to investigate the prevalence, characteristics, and treatment of hemorrhoids in Taiwan. Materials and Methods: This retrospective population-based study used data from the National Health Insurance Research Database and Taiwan Birth Certificate Application to collect the medical records of women who were pregnant at any time during 2009-2018. Hemorrhoids was defined by International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) (455. X) and International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) (K64.X, O22.4X) with related treatment. Results: We enrolled 1,608,804 deliveries in 1,070,708 women. The proportion of hemorrhoids increased with age in both primipara and multipara women. Of the pregnant women, 31% received oral medication, and 93.2% used the topical ointment to treat their hemorrhoids. Few patients (1.8%) required procedure or surgery during pregnancy, and 41.4% of those patients underwent procedure or surgery in their first trimester. The cumulative incidence of hemorrhoids during pregnancy was significantly higher in women with a history of hemorrhoids and those with multifetal pregnancies. No significant difference in the incidence of hemorrhoids was observed between multiparous and primiparous women. Conclusion: Women with a history of hemorrhoids or those carrying multiple fetuses had an increased risk of hemorrhoids during pregnancy. The most commonly used treatment for hemorrhoids during pregnancy was topical ointments, with only a small proportion (1.8%) of patients requiring procedure or surgery.

Comparison of the efficacy and safety of different surgical procedures for patients with hemorrhoids: a network meta-analysis

PURPOSE

This study used a network meta-analysis to evaluate the efficacy and safety of different surgical approaches in patients with hemorrhoids.

METHODS

PubMed, Embase, Web of science, and Cochrane Library were searched for randomized controlled trials on patients with hemorrhoids treated by different surgical procedures. The search was conducted until January 15, 2023. Two investigators independently screened the resulting literature, extracted information, evaluated the risk of bias of the included studies, and performed a network meta-analysis.

RESULT

A total of 23 randomized controlled studies were included and involved 3573 patients and 10 interventions, namely L (Ligasure), M-M (Milligan-Morgan), F (Ferguson), H (Harmonic), OH (open Harmonic), CH (closed Harmonic), PPH (procedure for prolapse and hemorrhoids), TST (tissue selecting technique), T-S (TST STARE+; tissue selection therapy stapled transanal rectal resection plus), and STARR (stapled transanal rectal resection). Network meta-analysis results showed that L has the shortest mean operating time and STARR has the longest mean operating time, F and H have the longest length of hospitalization and T-S has the shortest length of hospitalization, PPH has the most intraoperative blood loss and L has the least intraoperative blood loss, TST has the shortest time to first defecation and M-M has the longest time to first defecation, STARR had the least recurrence and PPH had the most recurrence, PPH had the least anal stenosis and L had the most anal stenosis, and F had the least postoperative pain after 24 h and PPH had the most postoperative pain after 24 h.

CONCLUSION

Current evidence suggests that L is best at reducing mean operative time and intraoperative bleeding, T-S is best at reducing mean length of stay, TST has the shortest time to first defecation, STARR is best at reducing recurrence rates, PPH is best at reducing postoperative anal stricture, and F is best at reducing postoperative pain after 24 h.

Evaluation of the efficacy and safety of an innovative flavonoid lotion in patients with haemorrhoid: a randomised clinical trial

OBJECTIVE

Haemorrhoids are one of the most common gastrointestinal and anal diseases. In olive oil and honey propolis, flavonoids have beneficial effects on improving vascular function and decreasing vascular resistance. In this study, we aimed to produce a combination of these two substances in the form of lotions and assess their healing and side effects in comparison with routine treatment, anti-haemorrhoid ointment (containing hydrocortisone and lidocaine).

DESIGN

In this randomised clinical trial study, 86 patients with grade 2 or more haemorrhoid degrees, diagnosed by colonoscopy, were divided into two groups, the case (n=44) and control (n=42). The case group was treated with flavonoid lotion, and the control group was treated with anti-haemorrhoid ointment two times per day for 1 month. Patients were followed weekly with history and physical examination. The data of the two groups were collected before and after the intervention and statistically analysed.

RESULTS

Post-treatment reduction in haemorrhoid grade was significant in the case group (p=0.02). This ratio was insignificant in the control group (p=0.139). Flavonoid lotion (p<0.05) significantly reduced the signs and symptoms of haemorrhoids more than anti-haemorrhoid ointment.

CONCLUSION

According to the results, flavonoid lotion can be an excellent alternative to topical chemical drugs, such as anti-haemorrhoid ointment, in treating haemorrhoid disease. Besides its effectiveness and safety, it can be easily manufactured and widely available to patien.

HEmoRhoidal disease management with Band ligation versus polidocanol Sclerotherapy: a systematic review and meta-analysis (the HerBS Review)

PURPOSE

Symptomatic internal hemorrhoids affect up to 40% of people in Western society. Patients with grade I-III hemorrhoids, who fail lifestyle and medical management, may benefit from office-based procedures. As per the American Society of Colon and Rectum Surgeons (ASCRS), rubber band ligation (RBL) is the first-line office-based treatment. Polidocanol sclerotherapy is a relatively new approach for these patients. The aim of this systematic review is to compare the efficacy of RBL and polidocanol sclerotherapy with the treatment of symptomatic grade I-III internal hemorrhoids.

METHODS

The systematic review was completed by searching MEDLINE, Embase, and CENTRAL databases from inception to August 2022 for prospective studies comparing RBL and polidocanol sclerotherapy or evaluating the efficacy of polidocanol sclerotherapy alone for adult (> 18 years) patients with grade I-III internal hemorrhoids. Treatments were evaluated for therapeutic success and post-procedure morbidity.

RESULTS

Of 155 citations obtained, 10 studies (3 comparative and 7 single-arm studies) and 4 abstracts (2 comparative and 2 single arm) were included in the study. The patients undergoing sclerotherapy had a 93% (151/163) therapeutic success rate compared to 75% (68/91) in the RBL group (OR 3.39, 95% CI 1.48-7.74, p < 0.01). The post-procedure morbidity was 8% (17/200) in the sclerotherapy group and 18% (23/128) in the RBL group (OR 0.53, 95% CI 0.15-1.82, p = 0.31).

CONCLUSION

This study highlights that polidocanol sclerotherapy may be associated with higher therapeutic success in patients with symptomatic grade I-III internal hemorrhoids. Further evaluations in the form of randomized trials are required to evaluate patient populations, which may benefit more from sclerotherapy.

A retrospective study on the pathologies in patients with coccydynia-lumbosacralgia and their treatment

BACKGROUND

The aim of this study was to arrange the treatment according to the etiology following the differential diagnosis in patients who had presented to the Orthopedics and Traumatology and General Surgery outpatient departments, and to emphasize the post-treatment success.

METHOD

The charts of 156 patients who had presented to the Orthopedics and Traumatology, General Surgery Departments of the Kafkas University Faculty of Medicine between July 2012 and June 2021 were retrospectively reviewed after permission was obtained from the ethics committee in this study. The demographic findings and Visual Analogue Scale (VAS) results for those with a symptom of pain as detected during the physical examination were recorded from the patient charts.

RESULTS

A total of 156 patients who had presented with traumatic and non-traumatic conditions to the Orthopedics Clinic complaining of pain, burning, sensitivity, discharge and hyperemia at the coccyx region were included in the study. The reason for the lumbosacralgia was found to be traumatic as in heavy lifting or working physically difficult jobs in 62 of the 95 patients (65.26%) who presented with lumbosacralgia and pain referred to the coccyx. The mean VAS was 7.37 before treatment and 2.32 following conservative treatment. There was a history of falling on the coccyx region in 8 of the 14 patients with traumatic isolated coccydynia. The pre-treatment mean VAS was 8.64 in the patients with a diagnosis of coccydynia while the post-treatment mean VAS was 0 in 8 patients with full recovery, 4.33 in 3 patients with partial recovery, and 9.66 in 3 patients with no recovery. The pre-treatment mean VAS was 7.58 in the 29 patients with thrombosed hemorrhoids, decreasing to 0 after treatment. The pre-treatment mean VAS was 4.16 in the 18 patients with a pilonidal sinus, again decreasing to 0 after treatment.

CONCLUSION

Possible underlying etiological factors should be taken into account when making a diagnosis in patients with coccydynia and the treatment should be determined in a multidisciplinary manner.

Perianal Abscess Following Excisional Hemorrhoidectomy in an Immunocompetent Patient

Hemorrhoidal disease is the third most common outpatient gastrointestinal diagnosis affecting more than four million patients annually. The management depends on the disease severity, and the treatment options range from lifestyle modification to excisional hemorrhoidectomy. Perianal abscess is an exceedingly rare complication following hemorrhoidectomy, with immunocompromised patients the most commonly affected. The rarity of this complication may be attributed to the natural immunologic process within the reticuloendothelial apparatus of the liver. The disease presentation of perianal abscess after hemorrhoidectomy and its management is unclear in the literature. We present the case of a 44-year-old immunocompetent male with grade II and III hemorrhoidal disease who underwent excisional hemorrhoidectomy that was complicated with perianal abscesses. The patient was successfully managed with incision and drainage with antibiotics. Surgeons should maintain a high index of suspicion for any sign of pelvic sepsis or a developing perianal abscess, particularly in immunocompromised patients.

Intero-External Hemorrhoids Complicated by Ischio-Anal Infection Coexisting with Tubo-Ovarian Abscesses: A Case for Early Surgical Intervention

Hemorrhoids are abnormal collections of engorged blood vessels and tissue within the anal canal or surrounding the anus. Management consists of conservative treatment or a hemorrhoidectomy, dependent on disease severity, duration, and physician discretion. Reported is a case of a 44-year-old, African American female initially treated conservatively for intero-external hemorrhoids, that later abscessed into the ischio-anal fossa and was further complicated by an infection of the deep pelvic space. This report explores conservative and surgical management of hemorrhoids, and offers recommendations for symptom management, and reducing disease progression and complications.

Micronized Curcumin Causes Hyperlocomotion in Zebrafish Larvae

Zebrafish larvae have been widely used in neuroscience and drug research and development. In the larval stage, zebrafish present a broad behavioral repertoire and physiological responses similar to adults. Curcumin (CUR), a major component of Curcuma longa L. (Zingiberaceae), has demonstrated the ability to modulate several neurobiological processes relevant to mental disorders in animal models. However, the low bioavailability of this compound can compromise its in vivo biological potential. Interestingly, it has been shown that micronization can increase the biological effects of several compounds. Thus, in this study, we compared the effects of acute exposure for 30 min to the following solutions: water (control), 0.1% DMSO (vehicle), 1 μM CUR, or 1 μM micronized curcumin (MC) in zebrafish larvae 7 days post-fertilization (dpf). We analyzed locomotor activity (open tank test), anxiety (light/dark test), and avoidance behavior (aversive stimulus test). Moreover, we evaluated parameters of oxidative status (thiobarbituric acid reactive substances and non-protein thiols levels). MC increased the total distance traveled and absolute turn angle in the open tank test. There were no significant differences in the other behavioral or neurochemical outcomes. The increase in locomotion induced by MC may be associated with a stimulant effect on the central nervous system, which was evidenced by the micronization process.

Investigating Knowledge toward COVID-19 Vaccination: A Cross-sectional Survey in Yogyakarta, Indonesia

AIM: Since there were pros and cons, and insufficient knowledge among Indonesian regarding the vaccines, this research aims to investigate the knowledge regarding COVID-19 vaccination among employees who work in an Islamic University in Yogyakarta, Indonesia. METHODS: A descriptive cross-sectional design was used to investigate the people’s knowledge of COVID-19 vaccination. The survey was conducted before the first vaccination of COVID-19 in March 2021. A descriptive analysis method was performed. Seven hundred sixty-two respondents completed the questionnaire. RESULTS: Respondent’s average age was 34.61 years old (standard deviation = 11.821, range 20–64), 54.1% of female and 45.9% of male. 448 (58.8%) respondents did not have any comorbid history. Respondents mostly obtained vaccination information through social media (86.25%). Most respondents had sufficient knowledge about the COVID-19 vaccine (83.2%), particularly those aged 20–29. For side effects, 585 (76.8%) respondents answered that they experienced pain in the injection area after getting the COVID-19 vaccination. This study showed that the respondents aged 20–29 years old had sufficient knowledge regarding COVID-19 vaccination. CONCLUSION: As knowledge plays an essential role in accepting vaccinations, health-care workers’ efforts to promote COVID-19 vaccination should be directed toward the middle-aged and elderly population to support the government’s plan to increase the rate of COVID-19 vaccinations in Indonesia.

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.

Herbal medicine AnoSpray suppresses proinflammatory cytokines COX-2 and RANTES in the management of hemorrhoids, acute anal fissures and perineal wounds

Hemorrhoids, anal fistula and fissure are common anorectal complications. Anorectal diseases are associated with severe pain, inflammation, swelling, itching and bleeding. These diseases may be managed with different medical treatments or surgical procedures, depending on their severity. Surgical procedures, however, are highly invasive and are associated with higher costs and the possibility of recurrence. In addition, surgical removal of fistula-in-ano leads to the formation of perineal wounds. Therefore, developing therapeutic interventions that are effective in alleviating inflammation and pain are desirable for the effective management of anorectal diseases. Herbal compounds have previously been indicated to suppress inflammation and pain in different pathological conditions. The aim of the present study was to examine the effects elicited by a polyherbal formulation, AnoSpray^®, on the migration of inflammatory cells and on the expression of inflammatory cytokines in anorectal diseases. The effect of AnoSpray on cell viability and migration was studied using MTT and wound-migration assays, respectively. Furthermore, the effects of AnoSpray on the expression of the inflammatory cytokines regulated upon activation, normal T cell expressed and presumably secreted (RANTES) and VEGF, as well as on cyclooxygenase-2 (COX)-2, were investigated using western blot analysis. The expression of RANTES and COX-2 in human hemorrhoid specimens was also analyzed to corroborate the in vitro findings. The results obtained revealed that AnoSpray did not exhibit any cytotoxic effects; however, it did lead to a significant suppression in the migration of RAW 264.7 and BJ cells. Furthermore, the results suggested that AnoSpray suppressed the expression of the inflammatory cytokines RANTES and VEGF, and also the expression of COX-2. In addition, RANTES and COX-2 were significantly downregulated in the clinical specimens of AnoSpray-treated hemorrhoids compared with the controls. Taken together, the results of the present study suggested that AnoSpray may be a potential therapeutic agent in the treatment of bleeding hemorrhoids, anal fissures and perineal wounds.

PREOPERATIVE USE OF MICRO-FLAVONOID FRACTION (MMF) AS PART OF A MULTIMODAL ANALGESIA IN ANORECTAL SURGERY: PROSPECTIVE, RANDOMIZED, PLACEBO-CONTROLLED, DOUBLE-BLIND STUDY PROTOCOL

Aim: To assess the efficiency of the micro-flavonoid fraction (MMF) administration prior to anorectal surgery with spinal anesthesia on postoperative pain severity reduction.Methods: Patients of our clinic who meet the following inclusion criteria are included: they must be diagnosed with surgical treatment of anorectal diseases. All participants are randomly divided into 2 groups: the first one gets a tablet with 1000 mg MFF (Detralex®), the second one gets a tablet containing starch per os 14 days before surgery (72 participants per arm). Then patients of each group will continue MFF administration for 30 days after surgery. Patients of both arms receive spinal anesthesia and undergo surgery. Following the procedure the primary and secondary outcomes are evaluated: frequency of the opioid drugs intake, the severity of the postoperative pain syndrome, duration and frequency of other drugs intake, readmission rate, overall quality of life, time from the procedure to returning to work and the complications rate, C-reactive protein level.Discussion: the MFF intake allows reducing the severity of the hemorrhoidal disease symptoms during conservative treatment. In addition, the Detralex® efficacy has been proven in postoperative pain reduction for patients diagnosed with varicose veins of the lower extremities. We intend to evaluate the feasibility of the preoperative MFF administration for the postoperative pain reduction and the decrease of the postoperative complications in patients with hemorrhoidal disease.

Preparation and In Vivo Evaluation of a Lidocaine Self-Nanoemulsifying Ointment with Glycerol Monostearate for Local Delivery

Lidocaine, a commonly used local anesthetic, has recently been developed into a number of ointment products to treat hemorrhoids. This study examined its efficient delivery to the dermis through the pharmaceutical improvement of hemorrhoid treatment ointments. We attempted to increase the amount of skin deposition of lidocaine by forming a nanoemulsion through the self-nanoemulsifying effect that occurs when glycerol monostearate (GMS) is saturated with water. Using Raman mapping, the depth of penetration of lidocaine was visualized and confirmed, and the local anesthetic effect was evaluated via an in vivo tail-flick test. Evaluation of the physicochemical properties confirmed that lidocaine was amorphous and evenly dispersed in the ointment. The in vitro dissolution test confirmed that the nanoemulsifying effect of GMS accelerated the release of the drug from the ointment. At a specific concentration of GMS, lidocaine penetrated deeper into the dermis; the in vitro permeation test showed similar results. When compared with reference product A in the tail-flick test, the L5 and L6 compounds containing GMS had a significantly higher anesthetic effect. Altogether, the self-nanoemulsifying effect of GMS accelerated the release of lidocaine from the ointment. The compound with 5% GMS, the lowest concentration that saturated the dermis, was deemed most appropriate.

Clinical study of herbal mixture "Diding Oral Medicine" as an alternative to preventative antibiotics in perioperative hemorrhoids: A CARE-compliant article

To study the clinical effects of Diding Oral Medicine as an alternative to preventative antibiotics in perioperative hemorrhoids.From August 2017 to February 2018, a total of 214 patients who were treated with external exfoliation and internal ligation of mixed hemorrhoids in our hospital were divided into the control group and experimental group by way of stratified random (107 cases in each group). Patients in the control group were given antibiotics preventatively before operation, while patients in the experimental group took Diding Oral Medicine before operation, and the white blood cell count, neutrophil count, wound recovery, pain score, anal bulge score, and pathogen culture of wound secretions were compared between the 2 groups.There was no significant difference in white blood cell count and neutrophil count between both groups before and after operation (P > .05). The wound seepage score, wound edema score, and wound area score in the experimental group were lower than those in the control group, and the wound healing in the experimental group was shorter than that in the control group (all P < .05). The pain score and anal bulge score of the experimental group were decreased significantly compared to the control group (P < .05). In addition, the detection rate of pathogenic bacteria in the experimental group was downregulated significantly compared to the control group (P < .05).The Diding Oral Medicine has prominent bacteriostatic and antibacterial effects on patients with hemorrhoids during perioperative period, and promotes wound healing, reduces pain stress, and anal bulge.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

This Practice Guidelines document has been co-published in Phlebology [DOI: 10.1177/0268355521999559] and Journal of Vascular Surgery: Venous and Lymphatic Disorders [DOI: 10.1016/j.jvsv.2020.12.084]. The publications are identical except for minor stylistic and spelling differences in keeping with each journal’s style. The contribution has been published under a Attribution-Non Commercial 4.0 International (CC BY-NC 4.0), (https://creativecommons.org/licenses/by-nc/4.0/)

With the support of the American College of Obstetricians and Gynecologists, the American Vein & Lymphatic Society, the American Venous Forum, the Canadian Society of Phlebology, the Cardiovascular and Interventional Radiology Society of Europe, the European Venous Forum, the International Pelvic Pain Society, the International Union of Phlebology, the Korean Society of Interventional Radiology, the Society of Interventional Radiology, and the Society for Vascular Surgery

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology (“SVP”) classification for PeVD, includes three domains—Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient’s disease. An individual patient’s classification is designated as SVP_A,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

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.

The Symptoms-Varices-Pathophysiology classification of pelvic venous disorders: A report of the American Vein & Lymphatic Society International Working Group on Pelvic Venous Disorders

As the importance of pelvic venous disorders (PeVD) has been increasingly recognized, progress in the field has been limited by the lack of a valid and reliable classification instrument. Misleading historical nomenclature, such as the May-Thurner, pelvic congestion, and nutcracker syndromes, often fails to recognize the interrelationship of many pelvic symptoms and their underlying pathophysiology. Based on a perceived need, the American Vein and Lymphatic Society convened an international, multidisciplinary panel charged with the development of a discriminative classification instrument for PeVD. This instrument, the Symptoms-Varices-Pathophysiology ("SVP") classification for PeVD, includes three domains-Symptoms (S), Varices (V), and Pathophysiology (P), with the pathophysiology domain encompassing the Anatomic (A), Hemodynamic (H), and Etiologic (E) features of the patient's disease. An individual patient's classification is designated as SVP_A,H,E. For patients with pelvic origin lower extremity signs or symptoms, the SVP instrument is complementary to and should be used in conjunction with the Clinical-Etiologic-Anatomic-Physiologic (CEAP) classification. The SVP instrument accurately defines the diverse patient populations with PeVD, an important step in improving clinical decision making, developing disease-specific outcome measures and identifying homogenous patient populations for clinical trials.

Belgian consensus guideline on the management of hemorrhoidal disease

Introduction

Hemorrhoidal disease is a common problem that arises when hemorrhoidal structures become engorged and/or prolapse through the anal canal. Both conservative and invasive treatment options are diverse and guidance to their implementation is lacking.

Methods

A Delphi consensus process was used to review current literature and draft relevant statements. These were reconciliated until sufficient agreement was reached. The grade of evidence was determined. These guidelines were based on the published literature up to June 2020.

Results

Hemorrhoids are normal structures within the anorectal region. When they become engorged or slide down the anal canal, symptoms can arise. Every treatment for symptomatic hemorrhoids should be tailored to patient profile and expectations. For low-grade hemorrhoids, conservative treatment should consist of fiber supplements and can include a short course of venotropics. Instrumental treatment can be added case by case : infrared coagulation or rubber band ligation when prolapse is more prominent. For prolapsing hemorrhoids, surgery can be indicated for refractory cases. Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids and is the only choice for non-reducible prolapsing hemorrhoids.

Conclusions

The current guidelines for the management of hemorrhoidal disease include recommendations for the clinical evaluation of hemorrhoidal disorders, and their conservative, instrumental and surgical management.

Hemorrhoidal disease and chronic venous insufficiency: Concomitance or coincidence; results of the CHORUS study (Chronic venous and HemORrhoidal diseases evalUation and Scientific research)

BACKGROUND AND AIM

The CHORUS study (Chronic venous and HemORrhoidal diseases evalUation and Scientific research) was conducted to provide data on patients presenting with hemorrhoidal disease (HD) in clinical practice and to explore the frequency with which it coexists with chronic venous disease (CVD) and shared risk factors.

METHODS

This international, noninterventional study enrolled adult patients attending a consultation for hemorrhoidal complaints. The questionnaire completed by physicians established the subjects' demographic and lifestyle characteristics and collected information on HD grade and symptoms and signs of CVD.

RESULTS

A total of 5617 patients were analyzed. Symptoms commonly reported were bleeding (71.8%), pain (67.4%), swelling (55.0%), itching (44.1%), and prolapse (36.2%). Multivariate analysis revealed the variables with the strongest association with HD severity were older age, higher CVD CEAP (Clinical manifestations, Etiologic factors, Anatomic distribution of disease, and underlying Pathophysiology) class, constipation, and male gender (all P < 0.0001). Elevated BMI was a risk factor for HD recurrence. Among women, number of births had a significant association with both HD grade and recurrence. The presence of CVD, reported in approximately half the patients (51.2%), was strongly associated with advanced grade of HD (P < 0.0001). Treatments most commonly prescribed were venoactive drugs (94.3%), dietary fiber (71.4%), topical treatment (70.3%), analgesics (26.3%), and surgery (23.5%).

CONCLUSIONS

CHORUS provides a snap shot of current profiles, risk factors, and treatments of patients with HD across the globe. The coexistence of HD and CVD in more than half the study population highlights the importance of examining for CVD among patients with a hemorrhoid diagnosis, particularly when shared risk factors are present.

Symptoms in Dilating Venous Disease

Lower extremity venous diseases or insufficiency include clinically deteriorating conditions with morphological and functional alterations of the venous system, including venous hypertension, vascular wall structural abnormality, and venous valvar incompetency in association with an inflammatory process. In fact, the same pathophysiological processes are the main underlying mechanisms of other venous insufficiencies in different vascular territories such as Peripheral Varicose Vein (PVV), varicocele, Pelvic Varicosities or Congestion Syndrome (PCS) and Hemorrhoidal Disease (HD). Regarding the anatomical continuity of lower extremity venous system, urogenital system (pampiniform plexus in male and broad ligament and ovarian veins in female) and anorectal venous system, it is reasonable to expect common symptoms such as pain, burning sensation, pruritis, swelling, which arise directly from the involved tissue itself. High coexistence rate of PVV, varicocele/PCS and HD between each other underlines not only the same vascular wall abnormality as an underlying etiology but also the existence of common symptoms originating from the involved tissue in dilating venous disease. Accordingly, it might be reasonable to query the common symptoms of venous dilating disease in other venous vascular regions in patients with complaints of any particular venous territory.

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.