Hemorrhoids prolapse is caused by a varicose dilation of the submucosal venous network of the anal canal, with a multifactorial origin (familiarity, obesity, posture, stress, constipation, pregnancy …).
Hemorrhoids have been one of the most frequent pathologies since ancient times. Hemorrhoids are vascular cushions, normally present in the terminal part of the rectum and in the anus in all people.
Their function is to participate in the discrimination of feces and the mechanism of continence. Internal hemorrhoids are distinguished, located in the part of the anal canal covered by the insensitive mucosa, and external.
Often after an inflammation (phlogosis) hemorrhoids remain on the outside of the small skin appendages called marische which are mistaken for external hemorrhoids.
For convenience, the haemorrhoidal disease is still classified according to the Goligher classification
- 1st degree: Hemorrhoids contained in the anal canal
- 2nd degree: The hemorrhoids come out on the push to re-enter immediately after defecation.
- 3rd degree: The hemorrhoids come out when pushed and their reduction is possible only manually.
- 4th degree: Hemorrhoidal prolapse is not reduced even manually.
Another view with respect to the classic Anglo-Saxon one has been provided by recent theories on rectal mucosal prolapse. According to the unitary theory of prolapse, hemorrhoids are an epiphenomenon of a mucous prolapse that drags the hemorrhoidal tissue with it. According to this theory the degrees are
- Internal or occult mucosal prolapse
- Mucous prolapse with invagination into the anal canal
- Complete prolapse with external leakage of the haemorrhoidal packets
- Complete prolapse with recto-rectal, rectal-anal and / or rectocele invagination
The symptoms of rmorrhoidal disease can therefore be divided into two groups - Vascular symptoms: bleeding, irritation \ itching acute pain (“hemorrhoidal thrombosis crisis”)
- Prolapse symptoms: Feeling of weight, incontinence (wet anus, soiling), obstructed defecation (excessive pushing to evacuate, incomplete evacuation, typing, enemas …), procidence, dermatitis
The diagnosis, necessary to exclude other pathologies, is based on the proctological examination and on the anoscopy.
According to some expert, in cases of bleeding after the age of 50, Colonoscopy, Defecography (colpocystodefecografia with ileal study) or DefecoRMN, TransRectal Ultrasound, Anorectal Manometry, are always indicated.
Therapies for Hemorrhoids prolapse
Hemorrhoid therapy consists of various medical therapies and multiple surgical interventions. Each patient is different and deserves a different treatment, surgery must be “tailored”. Always be wary of those who perform only one surgery for all patients and especially those who recommend the surgery in the first place
Medical therapy (phlebotonics, cortisone …) is indicated in the treatment of acute complications. It must be carefully assisted by a standard of life and a healthy diet and some hygienic names. It should be emphasized that, contrary to what is generally believed, it is not the cold that heals the haemorrhoidal disease in the acute phase, but the use of hot water, inhibiting sphincter hypertonia.
Sclerotherapy (and partially elastic ligation) is indicated in hemorrhoids of I-II-III degree or in more advanced cases but with impossibility to subject the patient to surgical treatment, in residual hemorrhoids \ postoperative relapses
The Surgical Treatment involves several techniques
Prolassectomy sec. Longo: consists of a lifting of the haemorrhoidal cushions by means of a cylindrical resection of rectal tissue that repositions the haemorrhoids upwards. Innovative and decisive intervention, especially reserved for cases where the symptoms of prolapse are predominant. Excellent control of postoperative pain. Complications are infrequent and mainly consist of urgency (inability to deliver the defecatory act when the stimulus is present; this complication resolves spontaneously in 3-6 months, only rarely lasts longer), postoperative bleeding, sphincter and rectal wall lesions (very rare).
Laser assisted hemorrhoidoplasty: minimally invasive and effective intervention, widespread in the Teutonic world. It consists of intravasal laser sclerosis (unlike other laser techniques where an attempt is made to photocoagulate through the rectum wall) with possible suspension of the prolapse upstream. (See more information in the laser surgery section)
Hemorrhoidectomy sec. Milligan Morgan: this is the most traditional of the various options, it consists of the excision of the hemorrhoidal goiters. Certainly effective in grade 4 hemorrhoids associated with vascular symptoms, it is also the operation burdened by the highest postoperative pain. The use of alternative devices (radiofrequency, etc.) instead of the scalpel did not show a particular reduction in pain
