II. Indications

  1. Thrombosed External Hemorrhoid
  2. No benefit if >72 hours from onset of thrombosis
    1. Thrombosis Hemorrhoid will resolve spontaneously

III. Contraindications

  1. Bleeding Disorder or Anticoagulation (relative contraindication)
  2. Overlying infection
  3. Immunodeficiency
  4. Internal Hemorrhoid

IV. Efficacy

  1. Improves short-term pain control
  2. Reduces risk of complication (e.g. appendageal Skin Tag formation)

V. Management: Preparation

  1. Patient positioning
    1. Left lateral decubitus position
    2. Assistant spreads patient's buttocks
  2. Confirm Thrombosed External Hemorrhoid
    1. External Hemorrhoids have squamous cell covering (Internal Hemorrhoids are covered in mucosa)
    2. Thrombosed Hemorrhoid is firm to palpation and typically have a purple hue
  3. Prepare perianal skin
    1. Topical Povidone-Iodine (Betadine) applied
  4. Anesthesia
    1. Avoid multiple injection sites (heavier bleeding)
    2. Consider Topical Anesthetic pre-medication before injection
      1. LET, LMX or ELA-Max
      2. Lidocaine 2% jelly applied to anal canal
    3. Local Anesthetic injection
      1. Inject 5 cc Lidocaine 1% with or without Epinephrine into Thrombosed Hemorrhoid
      2. Post-Epinephrine late heavy bleeding may occur
  5. Anoscopy
    1. Assess for other perianal pathologic findings

VI. Management: Hemorrhoidectomy

  1. Repeat perianal Skin Preparation with Betadine
  2. Confirm adequate Anesthesia
  3. Make radial incision over Thrombosed Hemorrhoid
    1. Extends from anal skin to distal edge of thrombosis
    2. Avoid circumferential incision (use radial only)
    3. Create eliptical incision (not linear)
    4. Consider using straight clamp placed below clot
    5. Use 15 blade or iris scissors to make incision
    6. Do not cut into underlying Muscle sphincter
    7. Avoid excessive cautery use (risk of scarring)
  4. Remove clot from incision
    1. Gently express thrombus from Hemorrhoid
    2. Examine wound for residual clots and remove with forceps
  5. Optional: Close skin with subcutaneous Suture (not routinely performed)
    1. Leave the excised Hemorrhoid open (not Sutured) in most cases
    2. May consider if increased bleeding risk
    3. Skin closure reduces bleeding without infection risk
    4. Place several interrupted buried Sutures (4-0 Vicryl)
    5. Sutures should not protrude through skin
  6. Bandage
    1. Apply topical antibiotic (e.g. Bacitracin)
    2. Apply 4x4 gauze

VII. Management: Post-Procedure Instructions

  1. Follow-up at 4-6 weeks
  2. Maintain soft stools (e.g. Colace, maximize hydration)
  3. See Hemorrhoid Management for general measures (e.g. Sitz bath)

VIII. Complications

  1. Late heavy bleeding (when patient is at home)
    1. Higher risk if Epinephrine used in Local Anesthetic
    2. Educate patient to apply direct pressure with gauze
    3. If patient returns for additional Hemostasis needed
      1. Inject Lidocaine with Epinephrine
      2. Silver Nitrate or hand held cautery for isolated source
      3. Surgicel
  2. Peri-anal Scarring
    1. Associated with excessive cautery use
  3. Anal stenosis (rare)
    1. Associated with circumferential incision
  4. Excision of other lesion (misdiagnosed as a Thrombosed Hemorrhoid)
    1. Internal Hemorrhoid
    2. Non-Thrombosed Hemorrhoid
    3. Skin Tag

IX. References

  1. Warrington (2018) Crit Dec Emerg Med 32(10):14
  2. Zainea in Pfenninger (1994) Procedures, p. 950-3
  3. Hussain (1999) Prim Care 26(1):35-51 [PubMed]
  4. Zuber (2002) Am Fam Physician 65(8):1629-42 [PubMed]

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