Polidocanol Foam: A Breath of Fresh Air for the Treatment of Internal Hemorrhoids

Hemorrhoidal disease is commonly diagnosed in clinical practice, ranging from 4% in self-reporting surveys [1] to almost 40% in screening colonoscopy studies [2]. Due to the intermittent nature of clinical symptoms, feelings of embarrassment or fear of examinations, patients often rely on coping strategies or opt for self-medication many years before getting medical care. Conservative treatment is successful for most patients with symptomatic grade I or II internal hemorrhoids, including dietary and lifestyle modification to reduce constipation and straining at defecation, as well as topical or oral medications to relieve symptoms [3], although there are few data on the long-term efficacy or side effects of most of these agents. For patients with symptomatic internal hemorrhoids refractory to conservative treatment, an office-based procedure such as rubber band ligation, sclerotherapy, or infrared coagulation, rather than surgical hemorrhoidectomy, should be recommended as the initial intervention. Surgical treatment is associated with more pain and more complications such as bleeding, anal deformity, and incontinence, being usually reserved for patients with permanently prolapsed grade IV hemorrhoids, concurrent symptomatic external hemorrhoids, or failure of nonsurgical treatment [4]. Although the preferred technique may depend on diverse factors such as local availability and expertise, rubber band ligation has often been recommended as the first choice for healthy patients especially with grade II or III internal hemorrhoids, generally providing a higher efficacy with fewer treatment sessions and fewer recurrences, although at the cost of a higher risk of complications such as pain and delayed bleeding when compared with sclerotherapy or infrared coagulation [5, 6]. One of the largest series evaluating the long-term outcomes of rubber band ligation achieved a success rate of 71% with a single procedure, reaching 80% when considering repeated treatment after initial failure [7].