Haemorrhoidal disease (HD) is the most common anorectal disorder. It has been managed by doctors since ancient times, and the treatment approaches have evolved over the centuries.

Modern medicine assumes a holistic approach to the patient, therefore, not only the stage of the disease is taken into account when choosing a treatment method, but also the patient’s age, profession, gender (the number and type of childbirths in women), symptoms, as well as expectations and preferred treatment approaches.

Most guidelines agree on the general management for HD. Lifestyle modification and anti-constipation diet are recommended in the initial stages. General and local medications are suggested during periods of disease exacerbation, while surgical treatment is reserved for advanced cases. Nevertheless, country-specific circumstances give rise to significant treatment differences in terms of the availability of different formulations, doses used, the components of combined preparations, their prices, etc., as well as the characteristics of a given population. Similarly, surgical treatment varies between countries. For example, infrared photocoagulation is rarely performed in Poland, whereas it is a treatment option for grade 3 haemorrhoids in most European algorithms (1). This may be related to the promotion of a given therapeutic technique among doctors and patients, as well as its availability in the public health service. Another reason for the differences is the lack of a clear advantage of a specific approach. Among other things, the opinions of experts on the most optimal surgical procedure, the Milligan-Morgan method vs. the Fergusson method, have been divided for many years (2).

We made an attempt to systematise data on etiopathogenesis, classification and conservative treatment of HR based on the current literature, as well as our own practical experience and observations.

The aetiology of HD is still a subject of research and theory. General agreement has only been reached on its multifactorial nature (3).

The first category of risk factors includes broadly understood gastrointestinal motility disorders, including defecation mechanism disorders. Knowledge of these conditions is essential for treatment planning. Constipation is one of the most frequently mentioned etiological factors in this category. Prolonged straining associated with hard faecal masses increases intraabdominal pressure and blood flow to haemorrhoids, while impairing venous outflow. This promotes haemorrhoidal enlargement (4). Nevertheless, the complex aetiology of constipation has had an impact on questioning the role of this etiological factor in HD (5). Currently, the issue of dyssynergic defecation is increasingly raised. Pelvic floor dyssynergia is associated with prolonged straining and difficulty in bowel movement, which may cause haemorrhoidal enlargement via the above described mechanism. Li et al. (6) showed that bowel movement disorders are associated with an increased risk of HD recurrence. The recurrence rates were 5.51, 38.46 and 60% in patients after surgical treatment, from minimally invasive procedures to haemorrhoidectomy, those with mild and moderate symptoms and obstructive defecation syndrome (ODS), respectively. Interestingly, diarrhoea is also reported as one of the important etiological factors.

The second category, i.e. environmental factors associated with the development of HD, includes a diet low in fibre, a sedentary lifestyle, obesity, previous pregnancies, and age. The important role of environmental factors is confirmed by the increased prevalence of HD in developed countries (7). The widespread use of toilets and the abandonment of squatting as a common bowel movement posture in these countries may be of great importance. Additionally, the prevalence of obesity has increased, and increasing BMI is a significant statistical risk factor for HD. An increase in the BMI of 1 increases the risk of haemorrhoids by 3.5% (8). The aging of the population accumulates the above-mentioned factors, from impaired intestinal motility and defecation mechanisms through a diet poor in fluids and fibre to a sedentary lifestyle, leading to increased morbidity in older age groups.

Genetic factors represent the last category. They may be related to dysfunctions of the Parks ligaments and the Treitz ligaments, which results in loosening of the suspensory mechanisms and haemorrhoidal prolapse upon filling with blood, with obstruction of blood outflow (9). Zheng et al. (10) identified over 100 genes, the expression of which in gastrointestinal blood vessels and tissues was associated with dysfunction of smooth muscles, epithelium and connective tissue, leading to HD. The history of haemorrhoids among many generations in a given family may confirm the role of genetic factors.

The Goligher classification has been used for years to grade HD (11). Despite some criticism regarding the failure to take into account the acute phase and the severity of bleeding in the classification (the Goligher classification is mainly based on the symptom of haemorrhoidal prolapse), it is still the most common classification system used by surgeons due to its simplicity in practical use. However, there have been many updates and revisions of the Goligher classification in recent years, which accounted not only for the degree of haemorrhoidal prolapse, but also other disease symptoms. These include the BPRST classification, where each letter corresponds to a disease symptom: B – bleeding, P – prolapse, R – reduction, S – skin tags, and T – thrombosis. Considering these 4 symptoms, researchers proposed 3 stages of haemorrhoidal disease with specific therapeutic recommendations, which translates into practical implications in the use of this scale (12). However, when reviewing the literature on newly proposed HD classification systems, it can be noted that almost all of them are based on the old classic Goligher classification.

A survey conducted among physicians in the Netherlands showed the need for a more reliable and internationally accepted HD classification system. As pointed out by the authors, the new classification system should be characterized by greater uniformity in the treatment of the individual stages of HD. The authors concluded that a Delphi study protocol is currently being prepared for the new classification system and conducted by an international research group (13).

The term dietary fibre refers to a highly heterogeneous group of chemical substances whose common feature is that they are not digested or absorbed from the gastrointestinal tract. The water-soluble fraction supports proper stool formation, while the water-insoluble fraction stimulates intestinal peristalsis. Fiber preparations available in Poland can be grouped based on the source of fibre (e.g. buckwheat, soy, etc.) or the form of the preparation (e.g. granulates, powders, tablets, etc.) (14). These formulations vary in their recommended daily dose of fibre. It is assumed that the recommended intake of fibre is about 25-38 g per day. Starting from a meta-analysis conducted in 2006 by Alonso-Coello et al. (15), all guidelines for the treatment of haemorrhoids point to a positive role of fibre. This study indicates that the risk of bleeding dropped by up to 50% in the group consuming fibre. Interestingly, no effect on pain reduction, haemorrhoidal prolapse or pruritus was observed.

Although it is a highly diverse group of compounds of plant origin (over 8,000 different flavonoids have been discovered so far), with a characteristic polyphenolic structure, diosmin and hesperidin are most often used in the treatment of HD. Flavonoids show antioxidant and anti-inflammatory effects, increase vascular wall strength and elasticity, and improve microcirculation. In their meta-analysis, Perera et al. (16) showed that flavonoids reduced pre- and postoperative bleeding, itching and mucus secretion, and were generally associated with symptom reduction. Their beneficial effect on alleviating pain has not been demonstrated either in the acute phase of HD or after haemorrhoidectomy. The dosage of diosmin is rarely addressed. According to the summary of product characteristic, the manufacturers of the preparations recommend 3 g per day for 4 days, and then 2 g per day for the next 3 days. Dimitroulopoulos et al. (17) used a dose of 3 g per day in two divided doses for 5 days, achieving bleeding resolution in 59.6% of patients after 5 days of treatment. The use of similar doses, i.e. 3 g per day in two divided doses for 3 days, followed by 2 g for 4 days, reduced the intensity of pain and analgesic consumption on days 2 and 3, as well as one week after haemorrhoidectomy (18). We also use flavonoid preparations in symptomatic HD without exacerbations, recommending a dose of 1x 1 g for about a month. Only single cases of their intolerance have been observed in clinical practice. Diosmin and hesperidin have a very similar action, although hesperidin is not available as an independent drug. Preparations composed of hesperidin further contain diosmin, rutin or vitamin C. Different products may contain from 22.5 mg up to 150 mg of hesperidin per one capsule.