Hemorrhoids are varicosities of the hemorrhoidal plexus. They affect about 25% of adults, with a prevalence between 50 and 80% in the age group from 50 years upwards, with no differences between the sexes1.
Often asymptomatic, they can, however, cause bleeding, even significant, typically after defecation, and pain, which can be very intense in the event of an acute attack, when the prolapsed hemorrhoids that remain blocked outside the anal sphincter become swollen and irreducible. inducing episodes of thrombosis and ulceration1,2,3. Pain usually resolves spontaneously within 7-10 days4 and thromboses are reabsorbed within 4-8 weeks2.
Depending on the severity, they are classified into I, II, III or IV degree hemorrhoids (see Table 1).
Diet and lifestyle habits
Hemorrhoidal disease is frequently associated with constipation4. Non-pharmacological measures, such as adding fiber to the diet, increased fluid intake and regular physical activity, can resolve constipation and, in the presence of grade I and II hemorrhoids, are sufficient to improve symptoms such as bleeding and "sense of discomfort", while they remain a complement to surgical techniques when the patient's picture supports the operation (see flow-chart) 3. Fiber supplementation reduces the frequency of bleeding episodes in patients with internal hemorrhoids, but has no influence on prolapse where it is present. The effect is not, however, immediate: it may take up to 6 weeks before any benefit is observed3.
Pharmacological treatments
Active ingredients for topical use
Various topical preparations (creams, ointments, ointments and suppositories) are available on the market for the symptomatic treatment of hemorrhoids (see Table 2). The active ingredients they contain include: astringent substances (for example, basic bismuth gallate and zinc oxide), local anesthetics (for example, tetracaine and lidocaine), corticosteroids (for example, hydrocortisone and fluocortolone), alone or in association. These products provide immediate relief, reducing pain and inflammation, without however correcting the underlying disease, but continued use for longer than 5-7 days is contraindicated as it can cause sensitization or atrophy (in the case of corticosteroids) anal skin and eczema3,6. It does not appear advisable, however, the use of ointments based on brewer's yeast extract (skin respiratory factor SRF; Preparation H ointment), except as emollients, as there are no studies that support the "vaunted" decongestant and pain-relieving properties8 .
Bioflavonoids
Flavonoids are pigments found in flowers, fruits and leaves of numerous plant species, including legumes and cereals. Some, for example rutin, diosmin and hesperidin, are present in pharmaceutical specialties [for example, diosmin (Alven and other specialties); hesperidin (Reparil, Edeven); purified and micronized flavonoic fraction, titrated in diosmin and hesperidin (Daflon, and other specialties)] which are proposed as adjuvants in the treatment of conditions of impaired capillary permeability, such as endothelioprotectors, as adjuvants in the treatment of varicose veins and hemorrhoids7. The benefits of a treatment with bioflavonoids, both in acute, to alleviate the symptoms, and in the long term to prevent possible relapses, have yet to be fully evaluated; however, currently available data seem to indicate that bioflavonoids are able to reduce bleeding episodes, the number of relapses and the severity of symptoms associated with the acute attack, in the case of nonprolapsed internal hemorrhoids9-14. Flavonoids are well tolerated; the most frequent adverse effects, usually minor and transient, concern the gastrointestinal system (abdominal pain, nausea, dyspepsia, vomiting and diarrhea). The alarmist rumors regarding an alleged danger, with an increased risk of the onset of leukemia in children born to women who had taken bioflavonoids during pregnancy, appear to date without foundation as they are not supported by the available data: studies conducted with flavonoids on women in fact, during pregnancy they did not show toxic effects on the fetus
