Hemorrhoid Treatment Needs a Relook: More Room for Conservative Management Even in Advanced Grades of Hemorrhoids

Dear Editor,

I read the article [1] with great interest. There are few points which I would like to add to the recommendations made in the article. These points are quite relevant in treating hemorrhoids.

First, there is now increasing evidence available of the role of conservative management especially fiber supplement (Psyllium husk) in the treatment of hemorrhoids including advanced hemorrhoids (grade III and late grade II). There are three root causes of hemorrhoids: prolonged time during defecation, increased frequency of bowel motions, and increased straining while defecation. If these three risk factors are removed (by TONE concept), then the hemorrhoids will not progress or rupture (bleeding) [2, 3]. Then most of the hemorrhoids would not need to be operated. TONE entails counseling the patient for, T—three minutes at defecation, O—once a day (frequency of motion), N—no straining while defecation, taking no newspaper/mobile in toilet, E—enough fiber. The first three components (TON) of therapy could be accomplished only if E (enough fiber) is taken correctly with diet [2, 3]. The correct method of fiber entails that the fiber has to be taken in adequate dose with sufficient amount of water [3]. Most of the publications in the literature have studied the efficacy of 1–2 teaspoonful (tsf) of fiber supplement. The fiber, in this dosage, is not fully effective. It needs to be taken at a dose of 4–5 tsf with at least 500 ml of water. There is a strong rationale behind this. An average adult requires up to 38–40 g of dietary fiber per day and the diet of most individuals these days consists of only 15–20 g fiber [2, 3]. So there is deficit of about 20–25 g of fiber intake per day which needs to be replenished. Therefore, the requirement of the fiber supplement is 4–5 tsf (20–25 g). For this to be fully effective, it needs to be taken with adequate water (500 ml) because the fiber would absorb water and make stools soft only when sufficient water is taken with it. Studies in large number of patients have demonstrated that when fiber is taken this way, it is effective in even advanced hemorrhoids [2]. It stops progression as well as decreases the size of hemorrhoidal prolapse and helps to prevent surgery in majority of patients with advanced hemorrhoids [2, 3]. Moreover, if the three risk factors are not removed, then there is high risk of disease recurrence even after surgery.

Secondly, the new classification proposed is a modification of existing classification. However, the need for this modification has not been outlined in the paper. The purpose of any classification is that it helps and guides the physicians regarding the treatment of the disease and helps to prognosticate the disease. But the suggested modification in the classification does not seem to alter the treatment guidelines from the existing guidelines in any way. Moreover, the modification in the classification is not backed or based upon any patient data. Therefore, the relevance and the need for this modification is questionable.

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Conflict of Interest

The author declares that he has no conflict of interest.