The Treatment of Hemorrhoids in Unusual Situations and Difficult Circumstances

The management of hemorrhoids varies widely based on disease severity and the individualized risks and medical history of each patient. Certain patients are particularly challenging for the surgeon, including those with pregnancy, immunosuppression from HIV/AIDS, portal hypertension, and inflammatory bowel disease. In general, almost all patients can be initially offered a conservative treatment regimen, including lifestyle and dietary modifications, improved perianal hygiene, and symptom relief. The indications for office-based procedures such as rubber band ligation, injection sclerotherapy, or infrared coagulation vary widely in these special groups of patients. Most therapies have not been well studied in the literature. Similarly, very little data exists pertaining to the safety and efficacy of operative hemorrhoidectomy in complex patients with hemorrhoidal complaints. Larger studies will be required before any additional conclusions can be reached regarding the optimal management of complex hemorrhoids. In the meantime, adopting a conservative approach and avoiding unnecessarily aggressive procedures will best serve surgeons and their patients.