Fourth-Degree Hemorrhoids: Treatment Options and Concerns

Q: Fourth-Degree Hemorrhoids: Treatment Options and Concerns

Hello, in response to your question： Rubber band ligation is generally used for second-degree hemorrhoids, but it can also be applied to smaller third-degree hemorrhoids. <br>The principle involves using a small rubber band to tie off the internal hemorrhoid, thereby obstructing

Hemorrhoid issues

Hello, doctor.
I apologize for bothering you, but I have more questions to ask.
Could you please explain why rubber band ligation is not suitable for fourth-degree hemorrhoids? At my age, it's really hard for me to accept the idea of undergoing hemorrhoid surgery.
I actually had hemorrhoids when I was fifteen, and it was second-degree at that time.
I underwent rubber band ligation treatment, which was painful for a week, and my family scolded me, making me feel very embarrassed.
Now, it has recurred, and it's at fourth-degree, leaving me unsure of what to do.
I really appreciate your advice, but hearing everyone suggest surgery makes me scared.
Also, why do hemorrhoids recur? I want to keep postponing treatment, but the external hemorrhoids are becoming increasingly painful, and the internal ones are getting larger.
It seems I have no choice but to accept treatment, but can I see a doctor during my menstrual period (which usually lasts over three weeks)? If I undergo traditional surgery, can it be done on an outpatient basis without hospitalization? What would happen if I choose not to have surgery? Why don't topical ointments work? It clearly states that they can reduce swelling! I apologize for asking so many questions and for any trouble I may have caused you.
Thank you for your response.

Xiao Feng, 20~29 year old female. Ask Date: 2010/01/02

Dr. Ke Fangxu reply Surgery

Hello, in response to your question: Rubber band ligation is generally used for second-degree hemorrhoids, but it can also be applied to smaller third-degree hemorrhoids.
The principle involves using a small rubber band to tie off the internal hemorrhoid, thereby obstructing its blood supply, which leads to necrosis and eventual detachment.
This procedure is feasible because the internal hemorrhoids lack sensory nerves, so patients typically do not experience pain, only a sensation of fullness.
However, many patients have reported excruciating pain post-ligation, which is often due to the ligation being too shallow and affecting the external hemorrhoids, which are innervated and thus painful.
A properly performed ligation should not cause significant pain.
Given your situation, it would be advisable not to delay further.
You can consult a doctor during your menstrual period, but surgery is recommended after menstruation ends for convenience, as post-operative care involves warm sitz baths.
Traditional surgery usually requires a three-day hospital stay due to more intense pain in the first three days.
After a week, pain should only occur during bowel movements, and normal activities can typically resume after two weeks.
If you maintain a healthy lifestyle and bowel habits post-surgery, recurrence can often be prevented for at least ten to twenty years.
Within the first week after surgery, you may experience abnormal sensations around the anus due to the surgical site, which can lead to feelings of urgency or incontinence, contributing to the myth of "post-surgical fecal incontinence." If surgery is not performed, hemorrhoids are likely to worsen, potentially leading to severe swelling and the formation of extensive thrombosed external hemorrhoids, which would necessitate surgery with a more complicated recovery.
While topical ointments can reduce swelling, your condition has progressed beyond simple swelling; it involves prolonged congestion and expansion of the hemorrhoidal tissue, akin to an inflated balloon.
This excess tissue cannot be resolved with ointments.
It is recommended that you do not hesitate to seek medical treatment promptly.

Reply Date: 2010/01/02

More Info

Fourth-degree hemorrhoids represent the most severe form of hemorrhoidal disease, characterized by the inability to reduce the hemorrhoids back into the anal canal. This condition often leads to significant discomfort, pain, and complications such as thrombosis or strangulation. The treatment options for fourth-degree hemorrhoids are limited, and understanding why certain methods, such as rubber band ligation, are not suitable is crucial for patients facing this diagnosis.

Why Rubber Band Ligation is Not Recommended for Fourth-Degree Hemorrhoids:
Rubber band ligation is a minimally invasive procedure typically used for treating first- to third-degree hemorrhoids. It involves placing a rubber band around the base of the hemorrhoid to cut off its blood supply, causing it to shrink and eventually fall off. However, in the case of fourth-degree hemorrhoids, this method is not advisable for several reasons:
1. Severity of the Condition: Fourth-degree hemorrhoids are often prolapsed and cannot be manually reduced. The ligation may not effectively address the underlying issue, leading to persistent symptoms and complications.

2. Risk of Complications: The risk of complications increases with the severity of the hemorrhoids. In fourth-degree cases, there is a higher likelihood of thrombosis or necrosis of the hemorrhoidal tissue if ligation is attempted.

3. Need for Surgical Intervention: Fourth-degree hemorrhoids typically require more definitive surgical treatment, such as hemorrhoidectomy, to remove the affected tissue and alleviate symptoms.

Concerns About Surgery:
It's understandable to feel apprehensive about surgery, especially if you have had a painful experience in the past. However, surgical options for fourth-degree hemorrhoids are often the most effective way to achieve long-term relief. Here are some considerations regarding surgery:
- Outpatient Procedures: Many surgical techniques for hemorrhoids can be performed on an outpatient basis, meaning you may not need to stay overnight in the hospital. Discuss this with your surgeon to understand the specifics of your case.

- Recovery and Pain Management: While surgery may involve some discomfort, modern techniques and pain management strategies can help minimize pain and facilitate recovery. Your healthcare provider can guide you on what to expect post-surgery.

- Menstrual Cycle Considerations: If you are menstruating, it is generally safe to consult with your doctor. They can assess your condition and determine the best timing for any necessary procedures.

Consequences of Not Treating Fourth-Degree Hemorrhoids:
Delaying treatment for fourth-degree hemorrhoids can lead to several complications, including:
1. Increased Pain and Discomfort: As the condition progresses, you may experience worsening pain, bleeding, and difficulty with bowel movements.

2. Risk of Thrombosis: The hemorrhoids can become thrombosed, leading to severe pain and swelling.

3. Infection: Prolapsed hemorrhoids can become susceptible to infection, which may require more extensive treatment.

4. Impact on Quality of Life: Chronic pain and discomfort can significantly affect your daily activities and overall quality of life.

Why Topical Treatments May Not Be Effective:
Topical treatments, such as creams and ointments, can provide temporary relief from symptoms like itching and inflammation but do not address the underlying structural issues associated with fourth-degree hemorrhoids. These treatments may reduce swelling and discomfort but are unlikely to resolve the prolapse or prevent recurrence.

Conclusion:
While the thought of surgery can be daunting, it is essential to consider the long-term benefits of addressing fourth-degree hemorrhoids effectively. Consulting with a colorectal surgeon can provide you with a clearer understanding of your options, including the possibility of outpatient procedures and pain management strategies. Remember, seeking treatment is a proactive step toward improving your health and quality of life.

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