Sugar can reduce edema in severe hemorrhoids. (Nitric Oxide Donors Also Work).

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ST. Louis -- Granulated sugar and topical nitric oxide donors are offbeat yet effective additions to the nonoperative treatment of internal hemorrhoids, Dr. Wayne B. Tuckson said.Granulated sugar is an effective way to reduce edema in patients with stage IV internal hemorrhoids, an excruciatingly painful condition that often constitutes a surgical emergency explained Dr. Tuckson, a colorectal surgeon in Louisville, Ky.Stage IV hemorrhoids are characterized by frill procidentia of the hemorrhoids and rectal mucosa, with considerable edema. The condition is often complicated by ischemia or necrosis. The patient can't manually reduce the hemorrhoids, Dr. Tuckson said at the 12th International Pelvic Reconstructive and Vaginal Surgery Conference.Stage IV hemorrhoidal disease is easily distinguished from rectal prolapse because prolapse features circular folds of tissue that come straight out toward the examiner. Internal hemorrhoids have three longitudinal sulci: the left lateral, right anterior, and right posterior bands. The distinction is key because the conditions are treated quite differently."Granulated sugar. It may sound stupid. The emergency room doc is going to think you're crazy. But you get some plain old table sugar, put it on a moist 4-by-4 or washcloth, and put that up against the anus. The edema will go down, and after that, the hemorrhoidal tissue can be excised using a circumferential Whitehead procedure or one of the other standard excisional techniques," he said at the conference, sponsored by the Society of Pelvic Reconstructive Surgeons.The therapeutic rationale for use of topical nifedipine, nitroglycerin, or isosorbide dinitrate is that these agents are nitric oxide donors. Nitric oxide is a smooth muscle relaxant--and the internal anal sphincter is a circular smooth muscle, he said."By applying this topically, we can decrease internal anal sphincter tone, allowing the muscle to relax. That's particularly important for patients with stage IV internal hemorrhoidal disease. You want the internal anal sphincter to relax to decrease swelling and allow the hemorrhoidal tissue to go back up into the anal canal better. It also decreases the patient's pain," the surgeon continued. These topical nitric oxide donors also are highly effective for anal fissures.None of these nitric oxide donors is commercially available in topical form. Dr. Tuckson has a pharmacist make up a topical 1% or 2% preparation. "The thing you've got to remember about these products, though, is that they are all cardiovascular agents," he said. Some patients complain of headaches after using it, so it is recommended that patients start with a low dose and titrate up slowly."I usually start them out with one application at night, since they can often sleep through the headache. Then I move them up to twice a day" Dr. Tuckson said.Another useful topical agent is ELA-Max 5% anorectal cream. It contains 5% lidocaine for dermal analgesia. Coupled with an oral antipruritic agent, it provides very good relief.