Hemorrhoids: Clinical Guidelines

List of Abbreviations

IAP – internal anal sphincter

НПВС – non-steroidal anti-inflammatory and antirheumatic drugs

НОШ – Numerical Rating Scale

РКИ – randomized controlled trial

УДД – levels of evidence certainty

УУР – levels of recommendation consensus

Terms and Definitions

The anal canal is the terminal part of the digestive tract, located between the lower ampullary part of the rectum and the external opening of the anus.

The dentate line is the line formed by the edges of the anal valves—pockets formed by the intestinal mucosa between the anal columns (columns of Morgagni).

Minimally invasive operations (procedures) are conservative surgical procedures or techniques that are not accompanied by severe pain and, as a rule, do not require special anesthesia or hospital stay. These interventions do not lead to prolonged disability and are accompanied by a relatively rapid rehabilitation period.

Radical surgery is a surgical procedure involving the complete removal of the disease substrate—i.e., in hemorrhoids, this is the removal of enlarged internal and external hemorrhoidal plexuses (hemorrhoidectomy).

Hemorrhoid recurrence is the reappearance of symptoms characteristic of the disease: bleeding during defecation, prolapse of internal hemorrhoids (provided that the nodes at this site were treated during surgery or a minimally invasive procedure).

1. Brief information on the disease or condition

1.1 Definition of the disease or condition

Hemorrhoids are a pathological increase in the volume of cavernous tissue in the anal canal (internal hemorrhoids) and/or in the perianal region (external hemorrhoids). Combined hemorrhoids involve the simultaneous enlargement of external and internal hemorrhoidal plexuses [1, Error! Bookmark not defined.].

Synonyms: hemorrhoidal disease.

1.2 Etiology and pathogenesis of the disease or condition (group of diseases or conditions)

The cause of the pathological increase in the volume of hemorrhoidal plexuses is acute or chronic circulatory impairment in the cavernous bodies. Along with circulatory disorders, degenerative changes in the suspensory apparatus of the hemorrhoidal plexuses play a significant role in the development of hemorrhoids [1–4].

Under the influence of these factors, internal hemorrhoidal plexuses increase in size and shift distally, while degenerative processes in the supporting apparatus increase, and the hemorrhoidal plexuses begin to prolapse from the anal canal. The development of degenerative processes in the conjoint longitudinal muscle of the submucosa of the rectum (Treitz's muscle) and Parks' ligament, which hold the cavernous plexuses in the anal canal, leads to a gradual but irreversible distal displacement of the hemorrhoidal plexuses [1–4].

1.3 Epidemiology of the Disease or Condition

Hemorrhoids are one of the most common human diseases and the most frequent reason for visiting a coloproctologist. The prevalence of the disease is 130–145 individuals per 1,000 adult population, and its share in the structure of diseases of the colon, anal canal, and perineum ranges from 39 to 41%. This condition occurs with equal frequency in men and women [1–5].

The modern pace of life is accompanied by physical inactivity (hypodynamia). Forced prolonged sitting at the computer, at work and at home, behind the wheel of a car, etc., is accompanied by circulatory stagnation in the pelvic organs, primarily in the rectum. This, in turn, leads to an increase in the incidence of hemorrhoids, which increasingly affect young, working-age people [1–5].

Every year in Russia, more than half a million people seek outpatient care for hemorrhoids from coloproctologists in state medical institutions, and about 60,000 of them receive inpatient surgical care. In 2018, the number of visits by patients with this disease, averaged across the constituent entities of the Russian Federation, was 304.9 per 100,000 population and is steadily growing every year. Taking into account outpatient medical care provided in commercial medical organizations, the total number of patients with hemorrhoids may exceed one million people annually [5].

1.4 Features of Coding the Disease or Condition

ICD-10 codes:

Chapter - Diseases of the digestive system (XI):

K64 Hemorrhoids and perianal venous thrombosis.

K64.0 First-degree hemorrhoids.

K64.1 Second-degree hemorrhoids.

K64.2 Third-degree hemorrhoids.

K64.3 Fourth-degree hemorrhoids.

K64.4 Residual hemorrhoidal skin tags.

K64.5 Perianal venous thrombosis.

K64.8 Other specified hemorrhoids.

K64.9 Unspecified hemorrhoids.

1.5 Classification of the disease or condition

Hemorrhoids are classified as follows [1–4, 6]:

1. By form:

· Internal.

· External.

· Combined.

2. By course:

· Chronic (Table 1).

· Acute thrombosed hemorrhoids (Table 2).

· Acute bleeding hemorrhoids (Table 3).

Table 1. Classification of chronic hemorrhoids

Table 2. Classification of acute thrombosed hemorrhoids

Table 3. Classification of acute bleeding hemorrhoids

1.6 Clinical presentation of the disease or condition

The main clinical symptoms of chronic hemorrhoids include: rectal bleeding during defecation (admixture of bright red blood with intestinal contents, bleeding in drops or a stream), prolapse of internal hemorrhoidal nodes from the anus during defecation, and the presence of enlarged external hemorrhoidal nodes (Table 4).

Table 4. Leading symptoms of hemorrhoids (examination data of 1,025 patients with hemorrhoids) [Error! Reference source not found.].

The main clinical symptoms of acute thrombosis of hemorrhoids include: pain in the anal and rectal region, and the appearance of a dense, painful mass(es) in the area of external and/or internal hemorrhoidal nodes.

Acute bleeding hemorrhoids are characterized by rectal bleeding ( profuse and/or recurrent) that cannot be stopped by conservative measures (suppositories, ointments, local cold application, venotonics/angioprotectors, etc.) and leads to the development of anemia.

An interview with a patient with hemorrhoids should begin with assessing their general condition. The presence of complaints such as weakness, shortness of breath, and dizziness should immediately alert the physician to the possibility of anemia resulting from chronic or acute blood loss. It is necessary to carefully ascertain concomitant diseases and analyze their treatment regimens, focusing on those groups of medications that may directly or indirectly contribute to the development of hemorrhoid symptoms. Up to 55% of patients with chronic hemorrhoids have a long-term history of the disease—from 5 to 15 years. This is due to the gradual development of the disease and the lack of motivational factors that most often prompt a patient to consult a doctor.

A typical symptom complex of hemorrhoidal disease most commonly consists of recurrent bleeding, usually associated with defecation, and the prolapse of hemorrhoidal nodes from the anus during and after defecation. All other manifestations of the disease are observed much less frequently, although the clinical presentation of hemorrhoids can be extremely varied [1-4]. Weakness, shortness of breath, dizziness, depression, bleeding, prolapse of masses from the anal canal, a sensation of a foreign body and incomplete bowel emptying, burning, pruritus, moisture, and pain are far from a complete list of complaints from patients with hemorrhoids. It must be remembered that any disease of the perianal region, anal canal, and colon can prompt a patient to visit a coloproctologist with complaints of "hemorrhoids".

The most characteristic feature of hemorrhoidal bleeding is droplet and/or jet-like rectal bleeding during and/or after defecation. Sometimes blood may be detected on the stool in the form of "streaks". In even rarer cases, blood may pool in the rectum, in which case clots and dark blood may be passed. The volume of blood lost can vary completely: from barely noticeable traces to profuse bleeding during every bowel movement [1.11.3].

The second most frequent symptom of chronic hemorrhoids is the prolapse of hemorrhoidal nodes. With the progression of the disease, node prolapse gradually increases—initially requiring manual reduction, and eventually the nodes cease to be reducible into the anal canal. Most often, all other symptoms of the disease join at this stage, forcing the patient to seek medical help. A sensation of discomfort, moisture in the anal region, pruritus, burning, a feeling of a foreign body in the perianal area and incomplete emptying, and mucous discharge from the rectum—all these symptoms are associated with the prolapse of internal hemorrhoidal nodes, their displacement into the anal canal or outward, and the contamination of the perianal skin with mucus and fecal masses. At the same time, pain is not a characteristic constant symptom of internal hemorrhoids. Most often, pain syndrome is accompanied by complications of hemorrhoids and/or concomitant rectal diseases, such as hemorrhoidal thrombosis, anal fissure, or anal fistula [1.2].

Completely different symptoms are observed in external hemorrhoids. Patients may note the presence of soft, elastic masses in the perianal region, sometimes causing only hygienic inconvenience. The clinical picture changes dramatically during thrombosis and inflammation of a hemorrhoidal node: a dense, painful mass appears in the anal area, accompanied by a pain syndrome of varying severity and systemic inflammatory response syndrome.

Hemorrhoidal thrombosis is a severe complication of chronic hemorrhoids, and one must never forget the possibility of inflammation spreading to the surrounding tissues and adipose tissue. Progression of the inflammatory process is an indication for hospitalization in a specialized unit for dynamic monitoring and deciding on emergency surgical intervention. A patient with hemorrhoidal thrombosis requires an extremely serious attitude from the physician; the literature describes clinical cases of the development of such formidable complications as Fournier's gangrene, etc. [1.3].

Acute bleeding hemorrhoids are characterized by single profuse and/or recurrent rectal bleeding. Blood from the anus may be passed in a stream or in drops, and the discharge of clots is also possible. In addition, characteristic symptoms of acute bleeding hemorrhoids include signs of anemia resulting from chronic blood loss: pallor of the skin, weakness, shortness of breath, and dizziness.

2. Diagnostics, medical indications and contraindications for diagnostic methods

The diagnostic criteria for "hemorrhoids" are the presence of enlarged internal and/or external hemorrhoidal nodes.

The diagnosis of "internal hemorrhoids" is established in the presence of enlarged internal hemorrhoidal nodes and the exclusion of other diseases with similar clinical symptoms.

The diagnosis of "external hemorrhoids" is established in the presence of enlarged external hemorrhoidal nodes.

The diagnosis of "hemorrhoidal thrombosis" is established in the presence of a compact, dense, mobile, rounded mass with a smooth "bluish" surface.

The diagnosis of "acute bleeding hemorrhoids" is established in the presence of a single episode of profuse and/or recurrent rectal bleeding leading to the development of anemia.

In most cases, clinical examination data are sufficient to establish the diagnosis of hemorrhoids.

At the same time, differential diagnosis must be performed to exclude other diseases of the anal canal, colon, and perineum (Appendix A3) [1-4]:

• benign and malignant neoplasms;

• anal fistula;

• anal fissure;

• rectal prolapse;

• inflammatory bowel disease;

• diverticular disease of the colon;

• angiodysplasia, etc.

Principles of formulation of the diagnosis.

When formulating the diagnosis, the presence of an external and/or internal component should be reflected, the stage of the disease in its chronic course should be indicated, and it is advisable to reflect the localization of the nodes according to the conventional clock face corresponding to this stage of the disease.

Examples of diagnostic formulations:

1. "Stage 2 internal hemorrhoids";

2. "Stage 3 external and internal hemorrhoids";

3. "Acute thrombosis of the external hemorrhoidal node at 7 o'clock";

4. "Internal hemorrhoids: stage 2 (3, 11 o'clock) - stage 4 (7 o'clock)";

5. "Acute bleeding hemorrhoids complicated by moderate anemia".

2.1 Complaints and Anamnesis

Hemorrhoids are characterized by the presence of etiological factors for the onset of the disease in patients: gastrointestinal disorders (constipation, diarrhea, unstable stools), dietary errors, alcohol abuse, sedentary and inactive lifestyle, heavy physical exertion, pregnancy, and childbirth.

Chronic hemorrhoids are typically characterized by complaints of prolapse of internal hemorrhoidal nodes from the anus during defecation and/or rectal bleeding during defecation (admixture of bright red blood to the stool, bleeding in drops or a stream), and the presence of enlarged external hemorrhoidal nodes. Less frequently, patients complain of a feeling of discomfort, moisture in the perianal region, pruritus, burning in the anal area, and mucous discharge from the rectum.

Acute hemorrhoids are typically characterized by complaints of pain in the anal and rectal region and/or the appearance of a dense, painful mass(es) in the area of external and/or internal hemorrhoidal nodes and/or ongoing or past bleeding from internal hemorrhoidal nodes with signs of anemia and/or hemodynamic disorders that cannot be stopped by conservative measures (suppositories, ointments, local cold application, angioprotectors, etc.) [1-4].

2.2 Physical Examination

• All patients with suspected hemorrhoids are recommended to undergo a physical examination to confirm the diagnosis [1-4]:

1. external inspection of the perineum and anal region;

2. digital rectal examination Strength of recommendation – C (Quality of evidence – 5)

Comment: the examination is performed in the lithotomy position, with the patient lying on their back with their legs pulled up as close to the abdomen as possible, or, if this is not possible, in the lateral position. An external examination of the perineal and perianal regions focuses on changes in the perianal skin (maceration, rashes, etc.), the shape of the anus, its patency, the presence of scars and deformations, the condition and prominence of external hemorrhoidal tags, the degree of prolapse of internal hemorrhoids, and whether they can be manually reduced into the anal canal. Stroking the skin of the perianal region is performed to assess reflex contractions of the anal sphincter.

Digital rectal examination should focus on the presence of enlarged internal hemorrhoids, their location and elasticity/firmness, degree of mobility, as well as the presence or absence of concomitant disorders of the anal canal and the lower ampulla of the rectum (anal fissure, anal fistula, neoplastic process, etc.). Digital rectal examination in acute hemorrhoids accompanied by severe pain may require local anesthetics.

2.3 Laboratory Diagnostics

Specific laboratory diagnostics for hemorrhoids do not exist. Laboratory diagnostic tests should be performed as part of preoperative workup and surgical planning to rule out comorbid conditions, as well as when differential diagnosis is necessary.

2.4 Instrumental Diagnostics

• Anoscopy is recommended for all patients with suspected acute or chronic hemorrhoids to examine the walls of the anal canal and distal rectum [11.3, 1.91.11].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

• Proctosigmoidoscopy is recommended for all patients with suspected acute or chronic hemorrhoids to detect comorbid diseases of the rectum and sigmoid colon and to perform differential diagnosis [11.3, 1.91.11].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

• Colonoscopy is recommended for all patients with suspected acute or chronic hemorrhoids and suspected concomitant large bowel diseases, as well as individuals over 45 years of age, for detection and differential diagnosis [4, 8].

SoR CQoE 5Strength of recommendation – C (Quality of evidence –5)

Comment: hemorrhoids are one of the most frequent causes of lower gastrointestinal bleeding; however, rectal bleeding is also one of the most common early symptoms of colorectal cancer and other colonic disorders (inflammatory bowel disease, colonic diverticular disease, etc.). Colonoscopy is recommended for individuals over 45 years of age, patients with a family history of colorectal cancer and other malignancies at a young age, inflammatory bowel disease, progressive weight loss, iron deficiency anemia, and other clinical situations requiring differential diagnosis and diagnostic clarification [1.1-11].

• An assessment of the functional state of the anal sphincter apparatus is recommended for patients with suspected acute or chronic hemorrhoids and suspected occult impairment of the anal sphincter function, as well as those with a history of rectal and anal surgery, to objectify its functional status [1.2, 12, 13, 1.14, 1.15].

SoR BQoE 4Strength of recommendation – B (Quality of evidence – 4)

Comment: hemorrhoidal cushions are important anatomical structures involved in involuntary continence. Because interventions on the cavernous bodies can lead to clinical symptoms of anal sphincter deficiency, assessing the function of the anal sphincter apparatus is essential for selecting an appropriate surgical method in patients at risk of anal incontinence (previously operated patients, elderly individuals (60 years and older), patients with clinical signs of perineal descent, women with a history of multiple and complicated deliveries (2 or more)). Sphincterometry is also important in patients with previous surgery, particularly for trans- and extrasphincteric anal fistulas [1, 12, 13, 1.14, 1.15].

2.5 Other Procedures

Additional instrumental and laboratory tests are performed for differential diagnosis in accordance with clinical guidelines for the diagnosis of the respective disease.

3. Treatment, including drug and non-drug therapies, diet therapy, and pain management

3.1 General Principles of Treatment for Acute and Chronic Hemorrhoids

The treatment of acute and chronic hemorrhoids aims to achieve the following goals:

1. normalization of gastrointestinal function;

2. relief of symptoms;

3. prevention of exacerbations and complications;

4. management of the wound healing process.

3.1.1 Diet Therapy

Considering the predominant role of gastrointestinal disorders (diarrhea, constipation) in the etiopathogenesis of the disease, adequate fluid and dietary fiber intake is advisable for all patients with acute or chronic hemorrhoids. When stool normalization fails with dietary modifications, laxatives may be used to establish regular, formed stools [13, 1.16-1.19].

The patient's diet should include foods rich in plant fiber and an adequate amount of fluid. It has been proven that a daily intake of 25 grams of dietary fiber increases bowel movement frequency in patients with chronic constipation. Fluid intake up to 1.5 - 2 liters per day increases stool frequency and reduces the need for laxatives in patients on a high-fiber diet. Wheat bran, kelp, and flaxseed, both in their natural form and as pharmaceutical preparations, are traditionally used as sources of dietary fiber in our country. Additionally, bulk-forming laxatives or macrogol-based preparations with high water-retaining capacity are used to normalize gastrointestinal function, helping patients avoid straining during defecation. Dosages are selected individually. However, conservative therapy aimed at normalizing gastrointestinal function is not an independent effective method of hemorrhoid treatment, especially for stage 3-4 disease [1].

3.1.2 Conservative Treatment

• Pharmacotherapy is recommended for all patients with acute and chronic hemorrhoids in order to [1.1-1.4]

1. relieve symptoms of acute hemorrhoids;

2. prevent complications;

3. prevent exacerbations in chronic disease;

4. prepare the patient for surgery;

5. provide postoperative rehabilitation.

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

Comment: basic pharmacotherapy for hemorrhoids includes both systemic and topical medications administered as gels, creams, ointments, and suppositories aimed at relieving disease symptoms.

Among systemic agents, bioflavonoids (C05CA), nonsteroidal anti-inflammatory and antirheumatic drugs for severe pain, and hemostatic agents for acute bleeding should be noted. The classification of main medications used in the pharmacotherapy of hemorrhoids is presented in Appendix A3 (Tables 1, 2, 3).

Bioflavonoids have a proven positive effect on hemorrhoid symptoms, reduce the risk of bleeding, disease progression, and complications. This group of drugs is recommended for use in accordance with the product labeling [1-4, 1.20-1.25].

3.2 Treatment of Chronic Hemorrhoids

3.2.1 Conservative Treatment

• Conservative therapy in accordance with general principles of hemorrhoid management (see section 3.1 General principles of treatment for acute and chronic hemorrhoids) is recommended for all patients with chronic hemorrhoids for symptomatic therapy, in case of refusal of proposed surgical treatment, and as part of a multimodal treatment approach [1.1-1.4].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

3.2.2 Minimally Invasive Surgical Methods

• For all patients with stage 1–3 internal hemorrhoids in cases of ineffectiveness or insufficient effectiveness of conservative therapy, it is recommended to perform minimally invasive surgical treatments: sclerotherapy, infrared photocoagulation, rubber band ligation, Doppler-guided transanal hemorrhoidal dearterialization, transanal hemorrhoidal dearterialization with mucopexy, and laser-assisted destruction of internal hemorrhoids [1.26, 1.27, 1.58, 1.61, 1.64, 1.77, 1.79].

GCR ALEL 1Grade of Recommendation – A (Level of Evidence – 1)

Comment: minimally invasive surgical treatments aim to reduce blood flow in hemorrhoids, decrease hemorrhoid volume, and fix them to the intestinal wall. The treatment method is chosen individually for each patient based on the leading symptoms of hemorrhoids, patient preference, the surgeon's experience, and the technical equipment of the medical facility. Despite minimal postoperative trauma, postoperative complications after minimally invasive surgery for hemorrhoids are observed in 1–6% of cases: dysuria, thrombosis of external hemorrhoids, severe pain syndrome, bleeding, purulent-inflammatory complications, etc. Complications such as Fournier's gangrene, pelvic peritonitis, obstruction, liver abscesses, and others have been described after minimally invasive surgery for hemorrhoids [1-4, 1.26-1.77].

• For patients with bleeding stage 1–2 internal hemorrhoids, infrared photocoagulation of hemorrhoids is recommended [1.35, 1.39, 1.40].

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

Comment: infrared photocoagulation of internal hemorrhoids is not recommended for patients with inflammatory diseases of the anorectal region and perineum. The efficacy of the method in early stages of chronic internal hemorrhoids reaches 71%. Possible postoperative complications include hemorrhoid thrombosis, pain syndrome, mucosal necrosis of the hemorrhoid, and bleeding.

The method is also indicated to stop bleeding in patients with any stage of hemorrhoids complicated by moderate to severe posthemorrhagic anemia and/or the impossibility of radical surgery [1-4, 1.36-1.40].

• For patients with bleeding stage 1–3 internal hemorrhoids, sclerotherapy of internal hemorrhoids is recommended [26, 35].

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

Comment: sclerotherapy of internal hemorrhoids is not recommended for patients with inflammatory diseases of the anorectal region and perineum, such as hemorrhoid thrombosis and acute paraproctitis. The efficacy of this method ranges from 76% to 91%. The postoperative period is characterized by low intensity or complete absence of pain syndrome. The incidence of postoperative complications does not exceed 9%. The most frequent ones are: thrombosis and edema of hemorrhoids, severe pain syndrome, necrosis and ulceration of the hemorrhoid mucosa in the injection zone [1, 1.26, 1.31-1.35].

The method is also indicated for arresting bleeding in patients with any stage of hemorrhoids when complicated by moderate to severe posthemorrhagic anemia and/or when radical surgical intervention is impossible. Varicose vein medications—sodium tetradecyl sulfate and lauromacrogol 400—are most frequently used as sclerosing agents [1-4].

• For patients with stage 2–3 internal hemorrhoids and the presence of separately located internal hemorrhoids with clear boundaries, hemorrhoid ligation is recommended [1.26, 1.35, 1.38-1.43].

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

Comment: hemorrhoid ligation is considered an effective method of minimally invasive hemorrhoid treatment and has a low recurrence rate. However, pain syndrome after ligation is more pronounced than after sclerotherapy and infrared coagulation.

Ligation of internal hemorrhoids is not recommended for patients with inflammatory diseases of the anorectal region and perineum, circular hemorrhoids, and the absence of clear boundaries between the external and internal components. In addition, this technique carries a risk of external hemorrhoid thrombosis and, in rare cases, inflammatory complications. Simultaneous ligation of more than 2 hemorrhoids increases the likelihood of vagal symptoms (bradycardia, hypotension, collapse) and severe postoperative pain, and also raises the risk of hemorrhoid symptom recurrence compared to staged procedures performed at 3–4 week intervals. Good treatment results are noted in 65–85% of cases [1-4, 1.26, 1.35, 1.38-1.45].

• For patients with stage 2–3 internal hemorrhoids, destruction of hemorrhoids using laser technology is recommended [1.27, 1.60, 1.61, 1.77].

GCR BLEL 2Grade of Recommendation – B (Level of Evidence – 2)

Comment: one of the modern and relevant trends in the treatment of chronic hemorrhoids is the use of laser technologies.

To date, there is significant terminology discordance in world literature describing the use of these technologies: "submucosal destruction of the internal hemorrhoidal plexus", "laser thermoablation", "laser obliteration", "laser hemorrhoidoplasty", "laser interstitial coagulation", "laser hemorrhoidoplasty (LHP)", "transmucosal destruction", "submucosal laser thermo-obliteration", "hemorrhoid laser procedure (HeLP)", etc. Consequently, there is a problem of method unification and synthesis of existing literature data. Laser radiation of varying power and wavelength is used to describe the same techniques, which also indicates a lack of developed guidelines for using this method in the treatment of chronic hemorrhoids.

We have attempted to summarize existing data from the world literature. Destruction of hemorrhoids using laser technology is not recommended for patients with inflammatory diseases of the anorectal region and perineum. Laser therapy is most effective in patients with stage 2 and 3 disease. In stage 2 disease, the efficacy of the method reaches 91–100%, and in stage 3, it is 69–70% [1, 1.27, 1.60, 1.61, 1.76, 1.77].

• For patients with stage 2–4 chronic hemorrhoids and clear boundaries between external and internal hemorrhoids, Doppler-guided transanal hemorrhoidal dearterialization with/without mucopexy is recommended [1.26, 1.27, 1.43, 1.45, 1.47, 1.50, 1.56-1.58].

GCR ALEL 1Grade of Recommendation – A (Level of Evidence – 1)

Comment: Doppler-guided transanal hemorrhoidal dearterialization is not recommended for patients with inflammatory diseases of the anorectal region and perineum, or fused external and internal hemorrhoids. The method is most effective in patients with stage 2 and 3 disease, with efficacy reaching 81%. Potential postoperative complications of the method include: severe pain syndrome (12–13%), tenesmus, acute urinary retention (5–8%), bleeding (0.9–2.2%), and external hemorrhoid thrombosis (2%). The method is recommended to be supplemented with mucopexy to reduce the degree of internal hemorrhoid prolapse.

When performing transanal hemorrhoidal dearterialization, the branches of the superior rectal artery are ligated in the lower ampullary rectum at a level 2–4 cm above the anorectal line. Mucopexy involves fixing the mucous membrane of the lower ampullary rectum [1-4, 1.26, 1.27, 1.43-1.59].

3.2.3 Surgical Treatment

• For all patients with stage 3–4 chronic hemorrhoids in whom minimally invasive surgical methods combined with conservative therapy are ineffective and/or technically unfeasible, removal of hemorrhoids (hemorrhoidectomy) A16.19.013 is recommended [1.26, 1.27, 1.64, 1.77, 1.79, 1.81, 1.84, 1.87, 1.90].

GCR ALEL 1Grade of Recommendation – A (Level of Evidence – 1)

Comment: hemorrhoidectomy remains one of the most effective methods of treating hemorrhoids. At the same time, the operation requires a long rehabilitation period and is associated with a relatively high rate of complications that are practically never encountered with other techniques.

The removal of hemorrhoidal nodes (hemorrhoidectomy) using traditional surgical instruments and/or diathermocoagulation, ultrasonic surgical scalpels, controlled bipolar coagulation, etc., is most frequently used. Wounds after the removal of hemorrhoids may or may not be sutured (open and closed hemorrhoidectomy). None of the types of hemorrhoidectomy has a significant advantage over the others. The choice of hemorrhoidectomy method is mainly determined by the surgeon's experience and the technical equipment of the medical institution. The use of modern and high-tech instruments in hemorrhoidectomy can significantly reduce the duration of surgery, reduce the intensity and duration of the pain syndrome, shorten patient rehabilitation times, and substantially decrease the frequency of dysuric disorders and other complications. Good results are achieved in 96.4% of operated patients.

The main disadvantages of hemorrhoidectomy are the prolonged rehabilitation period (up to 40 days) and a high percentage of postoperative complications: dysuria – 15-24%; severe pain syndrome – 34-41%; bleeding – 2-3%; purulent-inflammatory complications – 2-3%; stricture – 1-2%; anal sphincter insufficiency – 1.8-4% [1-4, 1.26, 1.27,Error! Reference source not found.-1.92].

• In patients with stage 2-4 chronic hemorrhoids combined with prolapse of the mucous membrane of the lower ampullary rectum, transanal mucosal and submucosal resection of the lower ampullary rectum using various staplers is recommended [1.26, 1.64, 1.66, 1.67, 1.69, 1.70, 1.77].

GGR BLEL 1Grading of Recommendations Assessment, Development, and Evaluation (GRADE) – B (level of evidence – 1)

Comment: transanal mucosal and submucosal resection of the lower ampullary rectum using various staplers (Longo procedure), despite preserving the hemorrhoidal nodes after the intervention, is not a minimally invasive surgical procedure, which is associated with full surgical risks: pain syndrome – up to 60%; anastomotic leakage – up to 6%; severe bleeding up to 48%. Complications such as rectovaginal fistulas, Fournier's gangrene, extensive pelvic hematomas, rectal stricture, acute intestinal obstruction, etc., have been described. Transanal mucosal and submucosal resection of the lower ampullary rectum shows a decrease in postoperative pain and a shorter patient rehabilitation period compared to traditional hemorrhoidectomy. However, the frequency of postoperative complications both in transanal mucosal and submucosal resection of the lower ampullary rectum and in traditional hemorrhoidectomy (open and closed) is approximately the same.

The goal of the surgery is fixation and lifting of the internal hemorrhoidal plexus through circular resection of the mucosal-submucosal layer of the lower ampullary rectum, which subsequently prevents the prolapse of internal hemorrhoids. The internal and external plexuses are not removed as a result of transanal mucosal and submucosal resection of the lower ampullary rectum [1-4, 1.26, 1.41, 1.45, 1.49, 1.50, 1.55, Error! Reference source not found.-1.78].

• In all patients with external hemorrhoids when conservative treatment is ineffective, excision of external hemorrhoidal nodes (removal of hemorrhoids) is recommended [1, 93].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

Comment: most often, patients with external hemorrhoids complain of the inability to perform adequate hygiene procedures and/or a cosmetic defect, as well as the occurrence of frequent thromboses of external hemorrhoidal nodes (more than 1 exacerbation per 2 - 3 months). As a rule, isolated external hemorrhoids are extremely rare, and "hemorrhoidal skin tags" are the consequence of a previously experienced acute thrombosis of external hemorrhoidal nodes.

Surgical intervention can be performed either in an inpatient setting in combination with other minimally invasive procedures aimed at eliminating symptoms of internal hemorrhoids or radical operations (in the presence of combined hemorrhoids), or in a day hospital setting (isolated external hemorrhoids).

3.3 Treatment of Acute Hemorrhoids

3.3.1 Treatment of Hemorrhoidal Thrombosis

• In all patients with grade 1-3 hemorrhoidal thrombosis, conservative therapy in accordance with the general principles of hemorrhoid treatment is recommended (see section 3.1 General principles of treatment of acute and chronic hemorrhoids) [1-4, 1.94-1.100].

GGR CLEL 4Grading of Recommendations Assessment, Development, and Evaluation (GRADE) – C (level of evidence – 4)

• In all patients with grade 1 hemorrhoidal thrombosis and severe pain, as well as the lack of effect from ongoing conservative therapy, excision of the thrombosed hemorrhoidal node or thrombectomy (evacuation of the thrombus) is recommended [1-4, 1.94-1.100].

GGR CLEL 4Grading of Recommendations Assessment, Development, and Evaluation (GRADE) – C (level of evidence – 4)

Comment: in acute thrombosis of hemorrhoidal node(s), conservative therapy aimed at relieving pain and the inflammatory process is recommended for circular thrombosis with pronounced edema and inflammation of surrounding tissues, as well as if the time from disease onset to the choice of treatment tactics exceeds 72 hours. This therapy includes: local use of combination drugs containing local anesthetics (e.g., lidocaine**, benzocaine), antithrombotic agents (sodium heparin** and other drugs), and corticosteroids, as well as systemic administration of bioflavonoids.

To date, a very small number of studies comparing various types of treatment for external hemorrhoid thrombosis have been performed, and those available provide a low level of evidence. Therefore, the choice of treatment tactics for this group of patients is decided individually, taking into account the surgeon's experience, patient preferences, and the capabilities of the medical institution.

Surgical intervention may be preferable to conservative therapy due to faster relief of disease symptoms. Most patients who present urgently (i.e., within 72 hours) can be helped by thrombectomy or excision of the thrombosed hemorrhoidal node under local anesthesia. At the same time, spontaneous resorption or evacuation of the thrombus can be expected in most cases; however, in such cases, a higher recurrence rate occurs compared to surgical treatment. The recurrence rate one year after hemorrhoidectomy is 6.4% versus 25.4% after conservative therapy. Thus, the choice of treatment tactics is determined taking into account the severity of the pain syndrome, patient wishes, surgeon experience, and the technical capabilities of the medical institution [1-4, 1.20-1.25, 1.94-1.100].

• In patients with grade 1-3 hemorrhoidal thrombosis during pregnancy and lactation, conservative therapy in accordance with the general principles of hemorrhoid treatment is recommended (see section 3.1 General principles of treatment of acute and chronic hemorrhoids) in cases where the benefit of therapy outweighs the risk to the fetus [1, 1.101-1.107].

GGR CLEL 5Grading of Recommendations Assessment, Development, and Evaluation (GRADE) – C (level of evidence 5)

• In patients during pregnancy and lactation with grade 1 hemorrhoidal thrombosis and severe pain, as well as lack of effect from ongoing conservative therapy, excision of the thrombosed hemorrhoidal node or thrombectomy (evacuation of the thrombus) is recommended in cases where the benefit of the intervention outweighs the risk to the fetus [1, 1.101-1.107].

GGR CLEL 4Grading of Recommendations Assessment, Development, and Evaluation (GRADE) – C (level of evidence –4)

Comment: in pregnant women, the incidence of hemorrhoids increases significantly compared to the general population, up to 25.7%, and reaches 49.8% in the postpartum period. Moreover, the proportion of acute hemorrhoidal thrombosis reaches 73%.

The goal of treatment for pregnant and nursing women with hemorrhoids is the prescription of adequate conservative therapy that does not harm the health of the mother and child and does not increase the risks to the life of the fetus.

Nevertheless, there are currently no data on the absolute safety of any regimens for treating hemorrhoids during pregnancy and breastfeeding.

The main principles of conservative therapy in pregnant and breastfeeding women are: normalization of gastrointestinal tract function; relief of pain using drugs approved for use during pregnancy and lactation (see the instructions for use of the drug registered in the State Register of Medicines of the Russian Federation); use of bioflavonoids; and prevention of recurrences [1-4, 1.101-1.107].

An indication for excision of a thrombosed hemorrhoid or thrombectomy under local anesthesia in the 2nd–3rd trimester of pregnancy is a long-standing thrombosed node accompanied by severe pain that is refractory to conservative therapy.

3.3.2 Treatment of acute bleeding hemorrhoids complicated by anemia of varying severity

• All patients with hemorrhoids complicated by ongoing or stopped bleeding are recommended to undergo conservative therapy in accordance with the general principles of hemorrhoid treatment (see section 3.1 General principles of treatment of acute and chronic hemorrhoids) [1-4].

GCR CLEL 5Grade of recommendation –C (level of evidence –5)

Comment: patients with hemorrhoidal bleeding may be prescribed topical medications containing hemostatic and/or vasoconstrictive components in the form of ointments and suppositories (hemostatic agents and other medications for the topical treatment of hemorrhoids and anal fissures, sympathomimetics, belladonna alkaloid combinations, and psycholeptics), bioflavonoids, as well as systemic hemostatic agents.

• All patients with hemorrhoids complicated by ongoing bleeding and a lack of response to conservative therapy are recommended to undergo emergency infrared photocoagulation, internal hemorrhoid sclerotherapy, or ligation/suturing of the bleeding node (see section 3.2.2 Minimally invasive surgical methods) [1-4, 1.26, 1.35].

GCR BLEL 2Grade of recommendation –B (level of evidence –2)

Comment: it should be borne in mind that the goal of emergency surgery is not to remove the bleeding node, but to stop the bleeding. Afterward, if necessary, post-hemorrhagic anemia is corrected (see relevant guidelines) and the disease is treated in accordance with the clinical guidelines for the management of chronic hemorrhoids (see section 3.2 Treatment of chronic hemorrhoids).

3.4 Prevention of Infectious Wound Complications After Surgical Treatment

• All patients following surgical treatment for hemorrhoids in the presence of extensive wounds or compromised immune status are recommended to be prescribed intestinal anti-infective drugs. The drugs may be administered parenterally or orally [1-3].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

4. Medical Rehabilitation and Sanatorium-Resort Treatment

• All patients who have undergone surgical treatment for hemorrhoids are recommended to undergo daily dressings in the postoperative period until wound healing, consisting of wound cleansing with antiseptic and disinfectant solutions (D08A) and application of anti-inflammatory and wound-healing ointment bases to the wound surface to reduce the risk of inflammatory complications [1-3]. Grade of recommendation – C (level of evidence – 5)

• All patients who have undergone surgical treatment for hemorrhoids are recommended to follow a high-fiber diet and take dietary fiber supplements in the postoperative period until wound healing to promote regular, soft stools [1-3].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

• All patients who have undergone surgical treatment for hemorrhoids are recommended to be followed up by a local coloproctologist or surgeon after discharge from the hospital during the wound healing period to prevent recurrences and complications [1-3].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

Comment: the need for patient rehabilitation is due to surgical trauma to the perianal area, anal canal, and lower ampullary rectum, with postoperative sutures at the sites of ligation of branches of the superior rectal artery. The presence of postoperative wounds (disruption of integrity) in these anatomical regions, their healing by secondary intention, and sutures at the sites of hemorrhoidal artery ligation entail a risk of purulent-septic complications and postoperative bleeding in the event of suture dehiscence. Pain of varying severity and potential impairment of defecation and continence in the postoperative period can lead to significant social maladjustment and reduce the quality of life in this category of patients.

General principles of rehabilitation after surgical treatment for hemorrhoids:

1) comprehensive assessment of the patient's baseline condition and formulation of a rehabilitation program;

2) drawing up a plan of diagnostic and therapeutic measures necessary for rehabilitation;

3) multidisciplinary approach to the organization of rehabilitation care;

4) monitoring the effectiveness of therapy during restorative treatment and at the end of the rehabilitation course.

Stages of patient rehabilitation after surgical treatment:

Stage 1 - early rehabilitation, from days 4–6 to days 7–10 after surgery. During this period, the patient receives inpatient rehabilitation for 3–5 days, after which further rehabilitation continues for 7–14 days in an outpatient setting or a short-stay hospital.

The most important objectives of stage 1 rehabilitation are the normalization of gastrointestinal function with the formation of normal stool consistency and frequency. In addition, at this stage, hemostasis and the wound process are monitored, and postoperative pain is managed.

Stage 2 - from day 15 to day 45 after surgery, aims to accelerate reparative processes and achieve geometrically correct, programmed healing of postoperative wounds while monitoring gastrointestinal function.

• Medical nutrition: one of the important components of early postoperative rehabilitation is the normalization of gastrointestinal function aimed at eliminating constipation and establishing normal stool consistency. To this end, patients are recommended to consume adequate amounts of fluids and dietary fiber. Wheat bran, kelp, and flaxseed in their natural form or as pharmacological preparations with high water-holding capacity are used as a source of dietary fiber, which helps soften stool consistency and promotes regular, complete defecation without the need for straining during rectal evacuation.

• Hemostasis control: following surgical treatment for hemorrhoids involving the removal of external and internal components of the cavernous tissue, the wounds are located in a highly vascularized area. Consequently, bleeding from postoperative wounds is frequently observed during the first 2–3 weeks after surgery. Rehabilitation measures for increased wound bleeding include regular inspection, application of ointment formulations with complex effects including capillary-strengthening properties, and normalization of stool consistency to limit excessive straining. Various topical hemostatic agents (B02BC) can be used, including sterile absorbable gelatin hemostatic sponges, as well as electrocoagulation of bleeding surfaces.

• Pain management: the severity of pain depends on the extent of surgical trauma to the perianal area and anal canal, individual pain threshold, and the presence of sutures on wounds of the anal canal and perianal region. Systemic or topical analgesics are selected individually by the attending physician depending on pain intensity and the severity of psychoemotional disorders.

• Programmed wound healing: one of the most critical aspects of postoperative recovery that helps prevent postoperative complications is the timely and topographically precise healing of postoperative wounds. Proper management of the wound process from the 2nd postoperative day until complete epithelialization involves: daily wound cleansing with antiseptic and disinfectant solutions (D08A), dressings with ointment applications (the composition of the ointment is determined by the stage of the wound process), dynamic evaluation by a coloproctologist (digital rectal examination performed every 48 hours), and microbiological monitoring (if purulent-septic complications and wound infection are suspected).

Main rehabilitation measures after surgical treatment of hemorrhoids.

After discharge from the hospital in the postoperative period, rehabilitation measures are necessary for all patients who have undergone surgical treatment for hemorrhoids. Depending on the severity of functional impairment, the complex of rehabilitation measures is carried out on an outpatient basis or in a inpatient rehabilitation bed.

• Defecation disorder – the patient requires mechanical bowel cleansing:

- performance of cleansing or siphon enema;

- prescription of osmotic laxatives (A06AD) with evaluation of their efficacy;

- mechanical removal of fecal masses under local or regional anesthesia.

• Pain syndrome (pain intensity on the Numerical Rating Scale (NRS) exceeds 6 points, Appendix G1):

- nonsteroidal anti-inflammatory and antirheumatic drugs using the parenteral route of administration;

- application of ointment compositions containing local anesthetic and anti-inflammatory components to wound surfaces;

- physiotherapy (ultraviolet irradiation, enzymatic, laser, ultrasonic, etc.).

• Monitoring of the wound process (if local and/or systemic nonsteroidal anti-inflammatory and antirheumatic drugs (M01) are required with dynamic local monitoring of the level of the inflammatory reaction, and the need for microbiological monitoring):

- treatment of wound surfaces with antiseptic solutions;

- application of water-soluble ointment compositions containing antimicrobial components, and ointments containing antibacterial components;

- systemic antibacterial drugs (J01) in tablet form or administered parenterally;

- wound discharge culture in case of pronounced inflammatory changes in wounds, suspicion of wound contamination with pyogenic flora, with dynamic monitoring 5–7 days after a course of antibacterial therapy;

- physiotherapy (ultraviolet irradiation, enzymatic, laser, ultrasonic, etc.).

Outpatient rehabilitation stage (may be carried out in a short-stay hospital setting) (days 15–45 after surgery).

The goal of the 2nd stage of rehabilitation for patients who have undergone surgical treatment for hemorrhoids is the final epithelialization of postoperative wounds and the prevention of postoperative complications. Also, during the 2nd stage of rehabilitation, monitoring of stool consistency and frequency, pain syndrome, and monitoring of the course of the wound process remain relevant.

To prevent cicatricial deformity and anal stricture, follow-up by a coloproctologist with transrectal digital examination of the rectum is required every 3–5 days.

5. Prevention and Dispensary Observation

5.1 Prevention

• All patients with the onset of the first symptoms of hemorrhoids are recommended a visit (examination, consultation) with a coloproctologist to determine the tactics of preventive measures aimed at preventing the development and progression of the disease [1-4].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

Comment: fundamental in the prevention of hemorrhoids is the normalization of gastrointestinal tract function, elimination of constipation, and adherence to hygiene regimens. If symptoms characteristic of hemorrhoids appear, a consultation with a coloproctologist is necessary. Timely diagnosis and treatment of the disease in the early stages can significantly improve the prognosis, reduce the likelihood of complications, and prevent further progression of hemorrhoids.

5.2 Dispensary Follow-up

• All patients who have undergone surgical treatment for hemorrhoids, after completion of treatment and wound healing, are recommended dynamic follow-up by a coloproctologist once every 6 months during the first year to improve disease control and prevent disease recurrence [1, Error! Reference source not found.].

SoR CQoE 5Strength of recommendation – C (Quality of evidence – 5)

6. Organization of Medical Care

6.1 Indications for hospital admission

Emergency hospitalization in a specialized coloproctological department is indicated for acute hemorrhoids accompanied by circular thrombosis of hemorrhoidal nodes, inflammation of surrounding soft tissues, and severe pain, as well as in cases of profuse and ongoing bleeding that is not stopped by conservative measures and leads to the development of anemia.

Elective hospitalization in a specialized coloproctological department is indicated for the chronic course of the disease or mild exacerbation accompanied by moderate pain, local thrombosis of one or more hemorrhoidal nodes, without inflammation of surrounding tissues.

Diagnostic procedures in an elective situation at the stage of diagnosis can be carried out on an outpatient basis. Surgical treatment must be carried out in a specialized inpatient coloproctological department and/or in a day coloproctology hospital setting.

6.2 Indications for patient discharge from a medical organization

In case of emergency hospitalization for acute hemorrhoids, the indications for discharge are the relief of acute manifestations of the disease and positive dynamics of the patient's condition: reduction of local inflammatory manifestations; decrease in the severity of pain syndrome with the possibility of its relief by oral medications in an outpatient setting; absence of signs of ongoing intestinal bleeding with the possibility of correction of posthemorrhagic anemia (if present) in an outpatient setting; the patient's ability (for patients with disabilities) to independently continue the course of conservative therapy in an outpatient setting under the supervision of a coloproctologist or surgeon.

In case of elective hospitalization for chronic hemorrhoids, patient discharge, depending on the nature of the surgical treatment, is carried out on days 2–5 after surgery. Indications for discharge are: uncomplicated course of the early postoperative period (absence of dysuria, increased bleeding tendency, etc.); absence of purulent-septic complications in the wound healing process; controlled pain syndrome with the possibility of its relief by oral medications in an outpatient setting; the possibility of independent full defecation after radical surgical treatment (discharge is recommended after the first bowel movement); the patient's ability (for patients with disabilities) to independently continue the course of conservative therapy in an outpatient setting under the supervision of a coloproctologist or surgeon.

7. Additional Information

Factors negatively affecting treatment outcomes:

1. Development of infectious complications;

2. Bowel dysfunction (diarrhea or constipation);

3. Patient non-compliance with the restrictive regimen and dietary recommendations.

Criteria for Evaluating the Quality of Medical Care

Quality assessment criteria for primary health care provided to adults with hemorrhoids (ICD-10 codes: K64)

Quality assessment criteria for specialized medical care provided to adults with hemorrhoids (ICD-10 codes: K64)

References

Appendix A1. Working Group Composition

All members of the working group are members of the Association of Coloproctologists of Russia. The clinical guidelines were discussed at the meeting of the Board of the Association of Coloproctologists of Russia (Minutes No. 3 dated 08.10.2022).

There is no conflict of interest.

Appendix A2. Methodology for Developing Clinical Guidelines

Target audience of the clinical guidelines:

1. Coloproctologists.

2. Surgeons.

3. Gastroenterologists.

4. General practitioners (family physicians).

5. General practitioners.

6. Endoscopists.

7. Nursing staff.

8. Medical students, residents, postgraduate students.

Table 1. Scale for assessing the reliability level of evidence (RLE) for diagnostic methods (diagnostic interventions).

Table 2. Scale for assessing the reliability level of evidence for prevention, treatment, and rehabilitation methods (preventive, therapeutic, and rehabilitative interventions).

Table 3. Scale for assessing the recommendation grades (RG) for prevention, diagnostic, treatment, and rehabilitation methods (preventive, diagnostic, therapeutic, and rehabilitative interventions).

Procedure for updating clinical guidelines.

The mechanism for updating the clinical guidelines provides for their systematic revision—at least once every three years, as well as upon the emergence of new evidence-based medicine data regarding the diagnosis, treatment, prevention, and rehabilitation of specific diseases, or the presence of justified additions/comments to previously approved clinical guidelines, but no more than once every 6 months.

Appendix A3. Reference Materials

These clinical guidelines were developed taking into account the following regulatory legal documents:

1. Clause 3 of Article 37 of Federal Law No. 323-FZ of the Russian Federation dated November 21, 2011, “On the Fundamentals of Protecting the Health of Citizens in the Russian Federation” (as amended and supplemented, effective January 11, 2023);

2. Order of the Ministry of Health of the Russian Federation No. 203n dated May 10, 2017, “On Approval of Criteria for Assessing the Quality of Medical Care”;

3. Order of the Ministry of Health of the Russian Federation No. 206n dated April 2, 2010 (as amended on February 21, 2020) “On Approval of the Procedure for Providing Medical Care to the Population with Coloproctological Diseases of the Colon, Anal Canal, and Perineum”;

4. Order of the Russian Ministry of Health No. 695n dated June 30, 2021, “On Approval of the Standard of Medical Care for Adults with Hemorrhoids (Diagnosis, Treatment, and Dispensary Follow-up)”

Table 1. Differential diagnosis of hemorrhoids.

Table 2. Main drugs for conservative treatment of hemorrhoids.

Note. NSAIDs - Non-steroidal anti-inflammatory and antirheumatic drugs.

Table 3. Main therapeutic effects and mechanisms of action of drugs used in the pharmacotherapy of hemorrhoids.

Appendix B. Physician Action Algorithms

Appendix B1. Algorithm for the diagnosis and treatment of a patient with acute hemorrhoids

Appendix B2. Algorithm for the diagnosis and treatment of a patient with chronic hemorrhoids

Appendix C. Patient Information

Disease information. Hemorrhoids are a disease characterized by the enlargement of external (external hemorrhoids) and/or internal hemorrhoidal plexuses (internal hemorrhoids). The condition may present as an acute process characterized by the appearance of firm, painful nodules that cannot be reduced into the anal canal (thrombosed hemorrhoid) or acute, heavy bleeding that cannot be stopped by local conservative measures. In such situations, depending on the severity of symptoms, emergency hospitalization may be required for conservative treatment under medical supervision, or in case of bleeding, for its prompt arrest. In the chronic course of the disease, accompanied by periodic bleeding and prolapse of internal hemorrhoids of various degrees, conservative treatment is of a supportive and symptomatic nature. If these symptoms progress, the patient is indicated for minimally invasive or radical surgical treatment. The choice of surgical method depends on the stage of the disease and the severity of the hemorrhoids. However, different types of interventions can be used for the same stage of hemorrhoids, so the final scope of surgery is chosen based on the specific situation, taking into account the patient's preferences regarding the treatment format. Depending on the type of proposed intervention, the expected level of pain syndrome, the degree and duration of disability may vary significantly.

Information required in the postoperative period. In the postoperative period, during the first 1–3 months after surgery, hygienic measures (bidet washing with cool water, sitz baths with chamomile decoction) and regulation of stool frequency and consistency are important. It is necessary to achieve regular daily soft stools that do not injure the wound surfaces in the anal canal and perianal region.

If difficulty in defecation or constipation develops, it is necessary to achieve stool normalization. Treatment of constipation, if not caused by conditions requiring surgical intervention, should start with prescribing a diet containing a sufficient amount of plant fiber, fermented milk products, and vegetable oil. Smoked foods, salted foods, marinades, cocoa, and chocolate are excluded from the diet; fried dishes, sausage products, and rye bread are partially limited. It is necessary to eat less bread and bakery products made from top-grade wheat flour (especially fresh and soft ones), pasta, and semolina dishes. Food with a high content of fiber and ballast substances (found in plant-based products, primarily grains) is recommended. Foods that contribute to stool normalization include: fresh kefir, prostokvasha (fermented baked milk), acidophilus. A positive effect is exerted by prunes soaked in water, figs, their infusion, plum juice, boiled beets, and dried fruit puree. Among first courses, soups, borscht, and cabbage soup based on a strong vegetable broth are useful.

Dietitians recommend pudding made from carrots, prunes, and apples with added lemon, beet puree, and vinaigrette salad with vegetable oil. In the mornings on an empty stomach, it is recommended to drink a glass of mineral water, fruit juice (plum, peach, apricot), or a hot lemon drink. A laxative effect is produced by grated carrots, raw apples, prostokvasha, and prunes eaten on an empty stomach. In addition, with a generally satisfactory condition, walks and minor physical activity are indicated. Morning gymnastics, physical exercises with an emphasis on abdominal muscles, and brisk walking are useful.

Pharmacotherapy for constipation should be carried out with great caution, in short courses, under medical supervision.

Additional recommendations for constipation:

1. Consult a doctor and find out which of the above recommendations you can use.

2. Drink 4–8 glasses of fluids per day.

3. Your diet should include foods that improve intestinal motility. We recommend whole-grain bread, bran crispbreads, porridges—buckwheat, oatmeal, wheat, pearl barley with milk or vegetable oil, and cereal dishes. Include fiber-containing foods in your diet (dietitians recommend adding raw vegetables and fruits, nuts, and sprouted wheat to milkshakes). Try oatmeal cookies and corn flakes.

4. Apples, figs, dates, and tea with lemon help some patients well.

5. Prune decoction is useful in the mornings and at night.

6. Be sure to add bran to your food, starting with one teaspoon per day. Then this amount should be increased to 4–6 spoons per day. Too rapid a dose increase may cause loose stools and flatulence. Try adding bran to porridges, rice or potato casseroles, and dairy products.

7. During antitumor therapy, take laxatives only as a last resort.

Appendix G. Assessment Scales, Questionnaires, and Other Evaluation Tools

Appendix G1. Numerical Rating Scale (NRS)

Russian name: numerological rating scale (NRS).

Original name (if applicable): the Numeric Pain Rating Scale (NPRS).

Source (official developer website, validation publication): https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2647033/pdf/main.pdf https://ascpt.onlinelibrary.wiley.com/doi/abs/10.1038/clpt.1983.159?sid=nlm%3Apubmed

Type: rating scale.

Purpose: the scale is designed to determine pain intensity, allowing an assessment of subjective pain sensations experienced by the patient at the time of examination.

Content (template):

Key (interpretation): according to the recommendations.

Explanations: this method of subjective pain assessment consists in asking the patient to mark a point on a 10 cm graduated line that corresponds to the severity of pain. The left border of the line corresponds to the definition "no pain", and the right border to "the worst pain imaginable".