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This article provides a practice-oriented overview of the most common proctological diseases: Anal eczema, hemorrhoidal disease, anal thrombosis, marisca, anal abscess and fistula, and anal fissure. Definitions and etiopathogenesis, clinic and diagnostics, and current therapy are presented., Competing Interests: Erklärung zu finanziellen InteressenForschungsförderung erhalten: nein; Honorar/geldwerten Vorteil für Referententätigkeit erhalten: nein; Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger: nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Sponsor der Veranstaltung): nein; Patent/Geschäftsanteile/Aktien (Autor/Partner, Ehepartner, Kinder) an Firma (Nicht-Sponsor der Veranstaltung): nein.Erklärung zu nichtfinanziellen InteressenDie Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: Hemorrhoids are a widespread disease. Treatment options range from dietary measures to open surgery. A novel treatment approach is the embolization of the hemorrhoidal arteries., Method: A review was performed based on a selective literature search in PubMed representing the current state of research. The keywords "hemorrhoid" and "embolization" and "emborrhoid" were used. In addition, technical details of the hemorrhoidal embolization procedure are explained., Results and Conclusion: Embolization of hemorrhoidal arteries is a safe treatment, which allows efficient symptom control even in patients with contraindications for open surgery., Key Points: · Embolization of hemorrhoidal arteries is a new approach to the treatment of hemorrhoids.. · Embolization of hemorrhoidal arteries is feasible in patients with contraindications for open surgery such as hypercoaguable states and contraindications for general anesthesia.. · The endovascular approach causes no rectal and anal trauma and associated complications can be avoided.. · The treatment of bleeding hemorrhoids seems to be particularly effective.. · No ischemic complications have been reported so far when coils as well as particles were used.., Citation Format: · Feyen L, Freyhardt P, Schott P et al. Hämorrhoidenembolisation: Eine neue minimalinvasive endovaskuläre Therapieoption bei Hämorrhoidalleiden. Fortschr Röntgenstr 2022; 194: 266 - 271., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Internal hemorrhoidal disease and non-surgical therapy Abstract. Haemorrhoids are a physiological part of the sphincter muscle which, under non-physiological conditions such as abdominal pressure, becomes enlarged and develops symptoms such as bleeding. The therapy consists of reducing the enlarged plexus. In addition to lifestyle adaptations, semi-invasive methods such as coagulation, rubber band ligations and, in more severe stages, surgical procedures such as the classic established methods (Milligan-Morgan, Ferguson, in selected cases Longo) can be considered.

Background: Laser haemorrhoidoplasty (LHP) with the 1470 nm diode laser in minimally invasive surgery for advanced haemorrhoid disease has been studied with respect to clinical variables, such as pain and complications, and intraoperative characteristics such as mucopexia, number of treated knots and energy consumed per patient. The study also included patient satisfaction, symptom relevance and cost effectiveness., Patients and Methods: Between November 2010 and November 2016, 497 patients (age 55 ± 14 years) were submitted to laser haemorrhoidoplasty with a 1470 nm diode laser in the centre for minimally invasive proctology in Siegen District Hospital. All operated patients were included in the study. Perioperative clinical and technical data up to 6 weeks and follow-up data up to 6 months were analysed prospectively., Results: The mean duration of operation was 14 min (± 5.2). A mean of 2.7 knots of 2.7 size were treated per patient. The mean postoperative pain was 2.5/10 (VAS). Long-term symptom relevance was 86%, and patient satisfaction 91%. Complications occurred in 49 patients (9.9%): bleeding 1.8%, infection 1%, urine retention 1.8%, oedema/thrombosis/prolapse 6.6%. 8.8% of patients suffered a relapse within 6 months. There were significant differences in pain on the day of the operation, and the parameters mucopexia, 3 treated segments and energy level > 500 J (p < 0.05). Complications were more common when mucopexia was performed, with 3 treated knots and energy consumed per patient > 500 J. The only significant difference was for energy level > 500 J (p < 0.05)., Conclusion: LHP is a safe, low pain and minimally invasive surgical procedure with long-term good patient acceptance and satisfaction and is suited for routine work. The energy applied should be reduced to a minimum. Complication rates are largely comparable with those of other minimally invasive conventional methods. Additional prospective studies must be performed, particularly in comparison to the Parks method, which gives similar functional results. With circular confluent findings, LHP cannot replace stapler hemorrhoidopexia., Competing Interests: Die Autoren geben an, dass kein Interessenkonflikt besteht., (Georg Thieme Verlag KG Stuttgart · New York.)

In proctology patients can often be helped with very little effort. With knowledge of the most common disease symptoms the treating physician can in many cases correctly recognize the cause of the complaints and initiate the appropriate therapy or arrange referral to a proctological institution. This article aims to briefly and succinctly present the most common diseases in proctology (e.g. mariscae, hemorrhoids, anal fissures, perianal venous thrombosis, abscesses and fistulas, condyloma acuminatum and anal carcinoma) and to provide the treating internist, even outside of gastroenterology, assistance with the management of proctological symptoms.

Up to one third of the general population suffers from symptoms caused by hemorrhoids. Conservative treatment comes first unless the patient presents with an acute hemorrhoidal prolapse or a thrombosis. A fiber enriched diet is the primary treatment option, recommended in the perioperative period as well as a long-term prophylaxis. A timely limited application of topical ointments or suppositories and/or flavonoids are further treatment options. When symptoms persist interventional procedures for grade I-II hemorrhoids, and surgery for grade III-IV hemorrhoids should be considered. Rubber band ligation is the interventional treatment of choice. A comparable efficacy using sclerosing or infrared therapy has not yet been demonstrated. We therefore do not recommend these treatment options for the cure of hemorrhoids. Self-treatment by anal insertion of bougies is of lowrisk and may be successful, particularly in the setting of an elevated sphincter pressure. Anal dilation, sphincterotomy, cryosurgery, bipolar diathermy, galvanic electrotherapy, and heat therapy should be regarded as obsolete given the poor or missing data reported for these methods. For a long time, the classic excisional hemorrhoidectomy was considered to be the gold standard as far as surgical procedures are concerned. Primary closure (Ferguson) seems to be superior compared to the "open" version (Milligan Morgan) with respect to postoperative pain and wound healing. The more recently proposed stapled hemorrhoidopexy (Longo) is particularly advisable for circular hemorrhoids. Compared to excisional hemorrhoidectomy the Longo-operation is associated with reduced postoperative pain, shorter operation time and hospital stay as well as a faster recovery, with the disadvantage though of a higher recurrence rate. Data from Hemorrhoidal Artery Ligation (HAL)-, if appropriate in combination with a Recto-Anal Repair (HAL/RAR)-, demonstrates a similar trend towards a better tolerance of the procedure at the expense of a higher recurrence rate. These relatively "new" procedures equally qualify for the treatment of grade III and IV hemorrhoids, and, in the case of stapled hemorrhoidopexy, may even be employed in the emergency situation of an acute anal prolapse. While under certain circumstances different treatment options are equivalent, there is a clear specificity with respect to the application of those procedures in other situations. The respective pros and cons need to be discussed separately with every patient. According to their own requirements a treatment strategy has to be defined according to their individual requirements.

Haemorrhoidal disease belongs to the most common benign disorders in the lower gastrointestinal tract. Treatment options comprise conservative as well as surgical therapy still being applied arbitrarily in accordance with the surgeon's expertise. The aim of this consensus statement was therefore to assess a stage-dependent approach for treatment of haemorrhoidal disease to derive evidence-based recommendations for clinical routine. The most common methods are discussed with respect of haemorrhoidal disease in extraordinary conditions like pregnancy or inflammatory bowel disease and recurrent haemorrhoids. Tailored haemorrhoidectomy is preferable for individualized treatment with regard to the shortcomings of the traditional Goligher classification in solitary or circular haemorrhoidal prolapses.

Improvements in our understanding of the anatomy of haemorrhoids have prompted the development of new and innovative methods of treatment. Conservative treatment consists of dietary and lifestyle modifications. Standard interventional procedures in outpatient treatment are injection sclerotherapy and rubber band ligation. Among the surgical options for prolapsed haemorrhoids, formal haemorrhoidectomy now competes with stapled haemorrhoidopexy, which is less painful and allows shorter convalescence but may have a higher recurrence rate and needs further long-term evaluation.

Background and Objective: Anal complaints, caused not by haemorrhoids but by anal folds, fissures or perianal thrombosis, are probably too often and wrongly attributed to haemorrhoids by patients and self-treated. It was the aim of this study to find out how frequently patients with anal complaints make this false assumption and how successful their self treatment is., Patients and Methods: 458 consecutive patients referred between May and November 2001 with unclear abdominal and/or anal symptoms were investigated by a standardized questionnaire/interview, including any experience with wet compresses, haemorrhoidal ointments or results of a doctor's treatment of haemorrhoids. They were then examined by procto-coloscopy. The findings were documented on the questionnaire and the data stored in an computer., Results: 344 of the 548 patients (63 %) believed that they had haemorrhoids, 184 (34 %) did not think so, and 20 (3 %) left the question unanswered. Haemorrhoids were found to be present in 18 % and 13 %, respectively. Bleeding, pain, itching and burning sensation around the anus were the most common symptoms in both groups. 151 of the 184 patients who did not think they had haemorrhoids (82 %) had been previously treated by a doctor for "haemorrhoids". 28 % of this group of patients and 36 % of those thought to have haemorrhoids had similar results with wet compresses, creams or ointments, and the two groups were also similar regarding the number found to have anal disease., Conclusion: Since many patients who had wrongly thought to have haemorrhoids had "treated" them successfully with wet compresses, creams or ointments, their complaints cannot be relied upon diagnostically. Doctors should not be misled by patients' complaints into assuming the presence of haemorrhoids and treat them, because this would incur unnecessary cost and bring little success.

Hemorrhoidal disease results from the pathological enlargement and distal displacement of the upper hemorrhoidal plexus. This disorder is very widespread in modern industrial society. Hereditary predisposition, malnutrition with constipation and abnormal bowel habits seem to be the most relevant causes for pathogenesis. The exact classification of hemorrhoids according to the degree of prolapse as well as the correct evaluation of accompanying anal diseases are very important in order to choose the appropriate conservative or surgical treatment with the goal of long-term avoidance of recurrence.

Haemorrhoidal symptoms have been known from time immemorial; they are considered to be a widespread problem, which is progressive if untreated. Treatment is according to the proctological qualification of the doctor and the degree of the changes. If possible, it should be carried out from the point of view of causal therapy. The most frequently occurring 1st degree haemorrhoids can almost always be treated conservatively, i.e. with sclerotherapy. To prevent recurrence, the life style and defecation habits should be changed. Regular monitoring by specialists aids prevention.

Hemorrhoids are a pathophysiological consequence of hyperplasia of the corpus cavernosum recti, and can be classified into three grades of severity. Clinically, they usually manifest in the form of peri-anal bleeding, a diffuse sensation of discomfort, itching and secretion of mucus. The diagnosis is established on the basis of the dinical presentation. Treatment is mainly conservative, but is likely to be successful only in the early stages. Already second degree symptomatic hemorrhoids require definitive treatment. Although peri-anal thrombosis is sometimes a very painful condition, it is usually harmless. If pain is severe, surgical incision is indicated.

Prevalence of hemorrhoidal diseases in proctologic practice has decreased over the past years. Inflammatory and functional diseases predominant as a consequence of improved differential diagnosis and diagnostic management. In less than 20% of patients of a specialized practice stage-adapted therapy is indicated. Favorable long term results, however, are barely obtainable without elimination of pathogenic factors. If inflammatory and/or functional disorders of the anal region are not eliminated relapses are preprogrammed.

Hemorrhoids are a very widespread disease causing pain by thrombosis, fear by bleeding and be a burden by weeping and pruritus. The different treatments show the different interpretations of physicians and patients. This paper will give a view of the most common and standardized procedures. Rubber band ligation is the most effective procedure in treating 1st and 2nd grade hemorrhoids. Surgical procedure is best in 2nd and 3rd grade disease. Recurrency is between 0.5 and 5% only. Technical development in surgical practice was leading to less pain in postoperative period by using diathermy, non-traumatic technique and avoiding of tampons. Using these principles hemorrhoidectomy allows a short hospital stay according to the individual needs of the patient. Special care should be given on urinary retention, the most common complication in anorectal surgery.

Main symptoms associated with hemorrhoids are anal bleeding, pruritus as well as weeping and superficial wounds of the rima ani and, finally, hemorrhoidal prolapse. The reason for the symptoms described is a relative anal incontinence due to hemorrhoidal knots prolapsing into the anal channel. There is evidence of an increased sphincteric pressure following increase of intraluminal pressure in colon and rectum in patients whose volumes of stool are too little because of small amounts of dietary fiber or regular use of laxatives. The stop of venous blood flow leads to a constant swelling of the vascular bed in the anal channel, which herniates during defection with variable intensity. Almost half of the patients suffering from hemorrhoids of grade 1 or grade 2 are treated successfully and conservatively (regulation of bowel habits by intake of large quantities of dietary fiber, change of life style and training of sphincter ani). Although injection therapy is used mostly, ligation of the prolapsing knots is the most physiological form of treatment: in retaining the vascular bed, the patient is able to keep complete continence. The consequent use of the former mentioned modes of treatment gives a 95% success rate in patients suffering from hemorrhoids. Only 5% need surgical intervention.

Painless bright red peranal bleeding is a leading symptom of first and second degree hemorrhoid. After having excluded the possibility of bleeding in an upper region diagnosis is made proctoscopically, which is generally followed by injection therapy. Arterial blood supply can be reliably imaged with the aid of 20 MHz microvascular Doppler sonography and the success of therapy can be verified as well as documented after injecting a sclerosing substance.

The various disorders occurring after sclerotherapy for hemorrhoids comprise excessive local reactions, necrosis followed by hemorrhage and allergic reactions. Symptoms, prevention and therapy of these adverse effects are detailed.

The treatment of piles should aim to reduce the abundant hemorrhoidal tissue in accordance with the stage (1. degree-3. degrees). In all cases an attempt should be made to regulate bowel function while avoiding straining. A high fibre diet is advised or a bulk laxative may be necessary. Advice on anal hygiene is given. If this treatment fails, infrared coagulation or injection sclerotherapy is indicated. Second or second to third degree hemorrhoids should be treated with rubber band ligation from the very beginning. In view of their possible complications, both methods should be used only by trained and experienced physicians.

Case reports of 1737 patients who were treated by cryotherapy have been analysed. The technique, indications, contraindications, complications and results of this therapy are described. This method gave a satisfactory result in 90% of the patients and 14% of the patients had severe pain immediately after the therapy. There are no follow-up results, because the treatment of haemorrhoids by cryosurgery is fairly new.