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Prevention of hemorrhoids includes drinking more fluids, eating more dietary fiber (such as fruits, vegetables and cereals high in fiber), exercising, practicing better posture, and reducing bowel movement strain and time. Wearing tight clothing and underwear may also contribute to irritation and poor muscle tone in the region and promote hemorrhoid development. Women who notice they have painful stools around the time of menstruation would be well-advised to begin taking extra dietary fiber and fluids a couple days prior to that time. Fluids emitted by the intestinal tract may contain irritants that may increase the fissures associated with hemorrhoids. Washing the anus with cool water and soap may reduce the swelling and increase blood supply for quicker healing and may remove irritating fluid. Many people do not get a sufficient supply of dietary fiber (20 to 25 grams daily), and small changes in a person's daily diet can help tremendously in both prevention and treatment of hemorrhoids.

MANAGEMENT Medical management is the initial treatment of choice for grade I internal and nonthrombosed external hemorrhoids. It consists of sitz baths (bid/tid); a high-fiber diet; adequate fluid intake; stool softeners; topical and systemic analgesics; proper anal hygiene; and in some cases, a short course of topical steroid cream. Good evidence exists that high fiber diets in particular help reduce severity and duration of symptoms. The prolonged use of topical steroids should be avoided. • Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset. o In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable. Internal hemorrhoids are treated according to their classification. Treatment may be surgical or nonsurgical. Most nonsurgical procedures currently available are performed in the clinic or ambulatory setting. o Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods. o Grade II or III hemorrhoids are initially treated with nonsurgical procedures. o Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy. Nonsurgical techniques function by ablation, sclerosis, or necrosis of mucosal tissues. Despite several meta-analyses and considerable personal preference, there is no clear advantage of one technique over the others. Contraindications to the nonsurgical treatments listed above include the following: o AIDS, Immunodeficiency disorders, Coagulopathy, Irritable bowel disease, Pregnancy, Immediate postpartum period, Rectal wall prolapse, Large anorectal fissure or infection, Tumor Surgical hemorrhoidectomy is the most effective treatment for all hemorrhoids and in particular is indicated in the following situations: o Nonsurgical treatment fails (persistent bleeding or chronic symptoms)

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Grade III and IV hemorrhoids with severe symptoms Presence of concomitant anorectal conditions (eg, anal fissure or fistula) requiring surgery o Patient preference About 5-10% of people with hemorrhoids eventually require surgical hemorrhoidectomy. Postoperative pain remains the major complication, with most patients requiring 2-4 weeks before returning to normal activities. Other possible complications include urinary retention, anal stenosis, and incontinence. o o

MEDICATIONS The goals of therapy are to reduce pain and constipation.  Docusate sodium (Colace): These agents are used to avoid straining and constipation. Indicated for patients who should avoid straining during defecation. Allows incorporation of water and fat into stool, causing stool to soften.  Lidocaine ointment 5% (Lidoderm, Dermaflex): Decreases permeability to sodium ions in neuronal membranes, resulting in inhibition of depolarization, blocking transmission of nerve impulses.  Hamamelis water (Witch Hazel): Mild astringent prepared from twigs of Hamamelis virginiana, used to temporarily relieve itching of hemorrhoids.  Acetaminophen (Tylenol, Aspirin Free Anacin, and Feverall): DOC for treatment of pain in patients with documented hypersensitivity to aspirin or NSAIDs, with upper GI disease, or who are taking oral anticoagulants. Reduces fever by direct action on hypothalamic heat-regulating centers, which increases dissipation of body heat via vasodilation and sweating. FOLLOW UP Further Outpatient Care • After excision of a thrombosed external hemorrhoid, the patient may be discharged home for several hours of bedrest followed by sitz baths tid, stool softeners, and topical or systemic analgesia. The patient should return in 48-72 hours for a wound check. All other patients should be referred to a surgical or rectal clinic for more definitive treatment and sent home with conservative medical therapy.

Complications • • • • • Thrombosis Secondary infection Ulceration Abscess Incontinence

Prognosis • • Most hemorrhoids resolve spontaneously or with conservative medical therapy alone. Recurrence rate with nonsurgical techniques is 10-50% over a 5-year period, while that of surgical hemorrhoidectomy is approximately 26%.