External Thrombosed Hemorrhoid - No Expert Consensus Redux

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External thrombosed hemorrhoid is what many sufferers type into Google to search for solutions to their rear end problems.
The experts call it thrombosed external hemorrhoid or TEH, in short.
It is understandable that the lay person can get the words in a different order.
But for a condition seen typically as non-life threatening, it is somewhat amusing that even the experts have so many synonyms for TEH! Medical researchers refer to TEH as acute thrombosed external haemorrhoid, acute hemorrhoidal disease, thrombosed hemorrhoid, hemorrhoidal thrombosis, perianal thrombosis, anal hematoma and perianal hematoma.
What an extensive list of names! Just to indulge those who searched and arrived at this article, we will continue to refer to TEH as external thrombosed hemorrhoid.
The varied medical nomenclature is symptomatic of the seeming lack of consensus among the experts of TEH.
The most basic of divergent views is in the etiology or causal factors of TEH, an aspect covered at length in a previous article.
We will move on to examine 2 prominent controversies, a golden rule and a gold standard, after clarifying the terms used in TEH.
An external hemorrhoid is one that forms distal (colloquially, south of) to the dentate line that demarcates the rectum and the anus.
Thrombosis is the formation of a thrombus or blood clot inside a blood vessel which can impede the flow of blood through the body's blood circulatory system.
External hemorrhoids are prone to thrombosis.
External thrombosed hemorrhoid can manifest as a circular thrombosis of external hemorrhoids surrounding the anal opening or it can be the thrombosis of a single external hemorrhoid.
It can lead to injurious inflammation in the entire anal and rectal regions.
Persistent pain often accompanies the condition and an urgent visit to the doctor is almost inevitable.
Golden Rule In 1983, J Alexander-Williams reminded us that "a baby's bottom has long been the yardstick of smoothness...
remarkably easy to clean...
after...
stool has been passed; one wipe with soft tissue usually suffices.
" He remarked that if the baby is not promptly cleaned, the skin will very soon become raw and excoriated.
The same apply to adults, it was postulated, when they leave minute particles of fecal material in the crevices of their own anal skin.
The golden rule, religiously followed in external thrombosed hemorrhoid treatment, was to keep the anal skin scrupulously clean, dry and protected from physical trauma.
Dry wiping of the skin was considered traumatic by J Alexander-Williams.
It was best to wipe with wet material, either by a jet of water, a moist cloth or cotton wool.
This must be done everyday.
Golden Rule? That the recommendation of J Alexander-Williams is the golden rule was affirmed by H.
Rohde in 2000 when he said it "became the bible of proctologists (specialist in diseases of the rectum and anus) world wide".
It was to be found in almost every article relating to the therapy of hemorrhoids, including external thrombosed hemorrhoid.
Unfortunately, Rohde points out, this golden rule has never been scientifically tested.
Rohde then boldly proclaims that, in his experience, these instructions may seriously harm a patient's peri-anal (i.
e.
around the anus) skin.
Another astounding statement was that the assumption that water is incapable of harming our skin is incorrect.
Going beyond bold words, Rohde tested his belief in a study of 46 patients with different types of peri-anal skin problems.
He instructed them to stop their daily routine cleansing habits and stick to a strict regime of cleaning their bottoms with a smooth DRY article.
There was to be no water, ointment, cream, gel, tampons, suppositories or sitz baths on their anus.
And? Of the 19 patients who completely adopted his instructions, none had any recurrence of their peri-anal problems! Gold Standard For external thrombosed hemorrhoid, surgery (as opposed to "conservative" or non-surgical treatment methods) is the gold standard, with the caveat that surgery is performed within the first 72 hours after onset.
Apparently, pain peaks around the third day and subsides thereafter so that surgery after 72 hours may actually cause more pain.
This gold standard is the result of several research papers, some dating as far back as 1979, most of which used the recurrence rate as a measure of success of the surgical route.
Unfortunately, as of now (Jan 2010), there are no randomized controlled trials (another gold standard, that of recognized scientific research) comparing surgical and non-surgical treatment methods for external thrombosed hemorrhoid.
Gold Standard? This gaping hole motivated the prospective cohort study of 72 adults with TEH by O.
Gebbensleben, Y.
Hilger & H.
Rohde to establish if there was at all a need for surgery to treat thrombosed external hemorrhoids.
Was it really necessary to remove the thrombus? The prospective cohort study was particularly useful in that they gathered a group of individuals with similar problems, i.
e.
a cohort of patients with TEH, and observed them over the next 6 months.
This had the advantage over retrospective cohort studies (most research was of this category) which merely collated statistical relationships from past data.
Instead of applying the gold standard to them, the cohort was given strict instructions to follow a conventional (i.
e.
non-surgical) regime to treat their external thrombosed hemorrhoid.
Given pain-killer medication, they were to adopt a wait-and-see policy and to perform only dry anal cleaning after motions.
There was to be no use of water, shower, bath, washcloth, wet wipes, soap or shower gel.
Only smooth dry toilet paper was to be used for anal cleaning after defecation.
And what did they find? 47.
2% of the cohort experienced no recurrences! The researchers concluded that more studies were needed and that ultimately, the gold standard of surgery within 72 hours may have to be abandoned.
Alternatives With the medical fraternity themselves in a seeming state of inconclusiveness over the treatment of external thrombosed hemorrhoid, it therefore seems logical that as laypersons, we should not be surprised if we get different advice from different doctors.
This is not to belittle the professionalism of medical experts but simply to highlight the complexities of the human anatomy and the medical infirmities that afflict humankind, be they life-threatening or otherwise.
But it does suggest that perhaps, laypersons should be more open to considering alternative remedies.
One such remedy is known as H Miracle which is popularly found on the internet.
Put together by a former hemorrhoid sufferer, it has many adherents, among those who suffer from hemorrhoids in general and external thrombosed hemorrhoid in particular.
Being natural, as opposed to pharmaceutical, explains much of its attraction.
Testimonials of recovered sufferers seem to carry much weight as well.
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