Topical therapies, especially controlled therapy with combinations of topical corticosteroids and anaesthetics are the cornerstone of achieving symptomatic relief of haemorrhoidal diseases, while defecation regulation is the only preventive treatment for haemorrhoid pathologies. In addition, post-therapy care should include dietary and lifestyle advice. These are the conclusions of the consensus panel of an international group of proctologists after a thorough evaluation of the clinical evidence and individual national approaches to treating haemorrhoidal disease in primary care.
The experts submitted their recommendations at the 21st Congress of the European Academy of Dermatology and Venereology (EADV) 2012. Reaching a consensus on the effects of topical and oral treatment of haemorrhoidal disease can be seen as a first step toward the creation of evidence-based guidelines for this disease.
Haemorrhoidal disease can have a substantially negative impact on a patient’s quality of life and social well-being. Studies have reported a wide range of prevalence between four per cent and 86 per cent. Only 10 per cent of patients undergo surgery, and fewer invasive measures are recommended at the beginning of the disease. Although the symptoms of haemorrhoidal disease are similar between countries, disease management often differs and there is a lack of generally accepted guidelines.
“Our consensus recommendations and algorithms offer practical treatment guidance for primary healthcare providers. Conservative treatments are recommended initially; thereafter, instrumental management has a high rate of success in special-care settings,” said Dr Gerhard Weyandt of the Department of Dermatology, Venereology, and Allergology at the Julius Maximilians-University Hospital Würzburg, Germany. “Further studies and clinical data are needed to consolidate these findings in order to produce evidence-based guidelines.”
According to the panel of international experts from Japan, Germany, France and Brazil, the controlled therapy with a fixed combination of a corticosteroid and a local anaesthetic should be preferred in cases where a topical corticosteroid formulation is chosen to treat pain. These combinations reduce pain quickly and treat inflammation effectively; they can be used to treat local symptoms, especially inflammation and swelling. By contrast, topical local analgesics may be useful at the beginning of therapy, but overall there is no indication for their general use in haemorrhoidal disease because of their side effects.
Although haemorrhoidal disease is one of the most common conditions in developed countries, there are substantial national and regional differences in disease management. The aim of the analysis was to arrive at a consensus on the value of non-invasive treatment for haemorrhoidal disease. The poster shows algorithms for management of haemorrhoidal disease which have been developed by a group of international clinical experts.
Haemorrhoidal disease occurs when the haemorrhoidal cushions, which are a normal part of the human anatomy, become enlarged. In severe cases, haemorrhoidal tissue may even protrude through the anus to the outside. These anatomical changes can be associated with bleeding, inflammation, itching, swelling and pain, and may sometimes lead to a severe impairment of the patient's quality of life. The widely used Goligher classification system describes four grades of piles based on the degree of prolapse.
It has not yet been clearly established what causes piles. Pathophysiologically, haemorrhoids are an abnormal dilatation of veins of the internal haemorrhoidal venous plexus, abnormal distension of the arteriovenous anastomosis and prolapse of the cushions and the surrounding connective tissue. Elevated anal sphincter pressure is presumed as a factor contributing to the disease. Risk factors include age, chronic constipation, overweight and laxative abuse. Moreover, the risk of haemorrhoidall disease increases with conditions such as pregnancy, ascites and pelvic space-occupying lesions that are associated with elevated intra-abdominal pressure which have been suspected to contribute to development of haemorrhoidall disease.
Creams, ointments and suppositories containing corticosteroids offer patients rapid symptom relief and alleviate the most uncomfortable manifestations of haemorrhoidal disease; they are also safe and convenient. Corticosteroids are well known for their anti-inflammatory effects. When locally applied, they alleviate pain, itching and burning, swelling and inflammation in the region being treated. Because of their higher lipophilicity, corticoid esters – e.g. prednisolone caproate, fluocortolone pivalate, fluocortolone caproate and difluocortolone valerate – penetrate the skin more easily than free corticosteroid alcohols. They are therefore frequently used in topical preparations. Moreover, the use of a fixed combination of a corticosteroid plus a local anaesthetic is supported by current medical practice. Adding an anaesthetic ameliorates pain and itching almost immediately and allows time for the anti-inflammatory action of the corticosteroid to take effect.