II. Indications
- Thrombosed External Hemorrhoid
- No benefit if >72 hours from onset of thrombosis
- Thrombosis Hemorrhoid will resolve spontaneously
III. Management: Preparation
- Patient positioning
- Left lateral decubitus position
- Assistant spreads patient's buttocks
- Prepare perianal skin
- Topical povidone-Iodine (betadine) applied
- Anesthesia
- Avoid multiple injection sites (heavier bleeding)
- Inject 5 cc Lidocaine 1% into Thrombosed Hemorrhoid
- Epinephrine may be used in Lidocaine
- Post-Epinephrine late heavy bleeding may occur
- Lidocaine 2% jelly applied to anal canal
-
Anoscopy
- Assess for other perianal pathologic findings
IV. Management: Hemorrhoidectomy
- Repeat perianal skin preparation with Betadine
- Confirm adequate anesthesia
- Make radial incision over Thrombosed Hemorrhoid
- Extends from anal skin to distal edge of thrombosis
- Avoid circumferential incision (use radial only)
- Create eliptical incision (not linear)
- Consider using straight clamp placed below clot
- Use 15 blade or iris scissors to make incision
- Do not cut into underlying muscle sphincter
- Avoid excessive cautery use (risk of scarring)
- Remove clot from incision
- Examine wound fo residual clots
- Close skin with subcutaneous Suture (4-0 Vicryl)
- Bandage
- Apply topical antibiotic (e.g. Bacitracin)
- Apply 4x4 gauze
V. Complications of Excision
- Late heavy bleeding (when patient is at home)
- Higher risk if Epinephrine used in local anesthetic
- Educate patient to apply direct pressure with gauze
- Peri-anal Scarring
- Associated with excessive cautery use
- Anal stenosis (rare)
- Associated with circumferential incision
VI. Post-Procedure Instructions
- Follow-up at 4-6 weeks
- Maintain soft stools (e.g. Colace, maximize hydration)
- See Hemorrhoid Management for general measures
VII. References
- Zainea in Pfenninger (1994) Procedures, p. 950-3
- Hussain (1999) Prim Care 26(1):35-51 [PubMed]
- Zuber (2002) Am Fam Physician 65(8):1629-42 [PubMed]
