Fourth-Degree Hemorrhoids: A Conservative Approach

In his "What's Your Diagnosis?" case of an older man with a prolapsed internalhemorrhoid (CONSULTANT, October 2002, page 1487), Dr Henry Schneidermanstates that the "patient and his family preferred a conservative approach." In thissetting, what would conservative management consist of?
---- Chris Patin, MD
Reno, Nev
Conservative treatment consisted of nonoperative measures: plentifulstool softeners to prevent scybalous trauma (which will exacerbateany anal or perianal mass), local desiccant and emollient, suppositoriesand enemas to minimize iatrogenic trauma to the area,and much reassurance that the mass did not have features suggestiveof cancer (Figure). Some surgeons or gastroenterologists might havesought biopsy material for histopathologic assessment and extirpated 1 or morelesions, but the conservative approach used in this patient was rationally selectedby a highly experienced surgeon in close consultationwith the attending geriatrician, the patient, the family, andthe nursing staff. Serial assessment over time then servedto exclude a coexistent incipient neoplasm. Had the patientsaid, "I don't mind a procedure; please just get rid of thisso I don't have to think about it," or had the anxiety of patient,family, or health care professionals been greater, adifferent approach would have been appropriate.
---- Henry Schneiderman, MD
Vice President, Medical Services
Physician-in-Chief
Hebrew Health Care
West Hartford, Conn
Professor of Medicine (Geriatrics)
Associate Professor of Pathology
University of Connecticut Health Center
Farmington