TREATMENT

The range of therapeutic options provided by Proctoclinic is wide, as the therapeutic options provided are adapted to the diagnosis set following the examination as well as to the particular conditions of each patient.

Treatment of the haemorrhoidal disease

Therapeutic principles

     1. As they are naturally occurring anatomical structures, the hemorrhoids are only treated when they become responsible for clinical symptoms.
      2. Hemorrhoids are crucial for continence, especially for gases and liquid feces; the therapy should respect the anatomical structures as much as possible.
      3. Currently, the surgical cure is no longer applicable to haemorrhoidal disorder therapy except for the failures of medical and instrumental therapy.
      4. The purpose of hemorrhoid therapy is to influence their mobility and the frail mucosa and not to remove in any situation and at any cost the respective venous dilations.

The therapeutic options in available for the haemorrhoidal disorder can be classified as medical (drugs), instrumental (non-surgical) and surgical.

The medical therapy is sometimes indicated for internal hemorrhoids first or second grade, with intermittent clinical manifestations, in patients with a general welfare altered consecutively to concomitant disorders and especially for the therapy of thrombophlebitis during which all direct therapies are usually contraindicated.

This is in fact a symptom-addressed therapy, aimed at attenuating / removing symptoms for a variable time, thus delaying the curative therapy (albeit non-surgical or surgical); the curative therapy is still eventually required since the evolution of the disease is certain. The medical therapy of the disease is hence not a curative method, capable of healing..

The scope of the instrumental therapy is to remove most of the haemorrhoidal mass, to prevent recurrences and to preserve a certain venous dilation in order to provide perfect anal continence.

Starting with a certain series of disadvantages and complications of the surgical interventions an impressive amount of techniques was imagined capable of reaching up to these standards.

All of these methods are considered non-surgical therapies and should represent the primary option for therapy for all first and second degree hemorrhoids non-responding to conservative therapy.

As experience grows, many of the third and, sometimes (occasionally) fourth degree hemorrhoids may also benefit of non-surgical therapy.

All instrumental methods have similar efficiency rates when used by experimented physicians, the choice of a particular technique regarding most often the preference and habits of the proctologist.

The techniques are usually applied under ambulatory care, with no hospitalization required and are applicable with the anuscope.

The purpose is hence not to completely destroy the hemorrhoid but to reposition it within the anal duct, following its reduction in size and attachment to the wall via fibrous scar formation canceling the prolapse and blood stasis, the determinant factors in the haemorrhoidal disorder.

Treatment of anal fissures

The anal fissures may evolve in about 50 % of situations towards spontaneous healing. The natural evolution in other situations is however towards chronic illness, supra-infection and occurrence of sentinel granuloma or hypertrophic papilla (secondary sources of pain), so that many times the therapy becomes a necessity.

The medical cure is always a first choice; it may heal more than 80 % of all cases and aims at suppressing pain and sphincter contracture. The goal of the therapy is hence to break the vicious circle consisting of constipation– pain – sphincter contraction – secondary constipation. The use of topical anti-haemorrhoidal drugs is contraindicated, since they cannot heal and they predispose to contact allergies, and the use of suppositories results in maintaining the illness due to the microtrauma induced which shall trigger via pain a characteristic vicious cycle.

Another option in the conservative therapy is a much more recent acquisition of acute and chronic anal fissure therapy, and namely the botulinic toxin. This is injected straight into the internal sphincter muscle, where it induces some sort of clinical sphincterotomy lasting up to three months; later on the tonus of the muscle becomes normal; throughout these three months the fissure usually heals and the symptoms are alleviated.

The botulin toxin is widely used in multiple disorders, the most familiar being the therapy of wrinkles in plastic surgery.

The surgical therapy is the final option in the therapy of anal fissures, since it is reserved for conservatively untreatable fissures, including the botulinic toxin and for the complicated (fistula, deformities alterations of previous interventions, abscesses, etc.). Usually there are two preferential options:
• anal dilation – this procedure represents a dilation aiming at the so-called controlled breaking (actually it is impossible to control due to the wide human diversity of patient, since each patient imposes a particular situation), of some of the muscular fibers of the internal sphincter under general anesthesia. Its reasons consist of depicting in some patients of some fibrosis of the muscular fibers incapable of relaxation, so that the fissure cannot close. Though the procedure obviously improves or alleviates the symptoms, it is rarely used nowadays since there is a risk for definitive incontinence due to the lack of control when breaking the internal sphincter fibers and to the possibility to simultaneously injure the external sphincter.
• internal sphincterotomy – the aim of the intervention is to section the hypertrophic internal sphincter which leads to a decrease in its tension and implicitly to the healing of the fissure. The post-surgical pain is quite important even though they are not more significant than the pain due to the fissure itself, regardless of the choice of procedure (albeit closed or not). The consecutive complications may be represented by bleeding, infection, post-surgical fistula, anal incontinence, recurrence or lack of healing.

Treatment of anal and perianal suppurations (infections)

Antibiotic therapy (administration of antibiotics) can at most reach up to a chronic evolution of the inflammatory process, since the infectious process evolves, as antibiotics cannot reach into the septic and necrotic focus during the persistence of the septic contamination process.

Therefore, all perianal collection should be incised immediately following diagnosis, as it represents a surgical emergency.

In ambulatory care some of these suppurations may also be treated (sub-mucous abscesses, lower sphincter abscesses, crypt and papilla infections).

The other infections usually require immediate hospitalization in surgical units since the immediate surgical intervention is typically required.

In our clinic all these septic collections are treated using radiofrequency, the method with the best effects with the lowest collateral damages.

A daily bandage is required as well as special hygiene measures, which the patient may use on its own at home (water, soap, antibiotic ointment). For such situation the hospitalization of the patient is no longer required and the patient may carry on with the daily chores.

The most important fact about these collections is that they need to be properly diagnosed, due both to their possibly severe evolution if neglected or if their therapy is delayed (up to septicemia!), and to the fact that such septic collections might alter the healing of other lesions the therapy of which is prone to failure (supra-infected fissures, suppurated marisca, fissures associated with sub-mucous abscesses) and, last but not the least, due to the fact that they result in major clinical symptoms (pain !).