Piles (Hemorrhoid) Surgery in Pokhara: Modern Treatment Options at A&B

Hemorrhoids — known in Nepal as piles or bawaseer — are enlarged, engorged veins in and around the lower rectum and anus. They are one of the most common conditions presenting to general surgeons in Nepal, yet many patients suffer in silence for years before seeking medical care due to embarrassment. Effective treatments exist for every grade — from simple dietary changes to surgery.

What Are Hemorrhoids and How Are They Graded?

Hemorrhoids are cushions of vascular tissue present in everyone. They become symptomatic when the supporting connective tissue weakens, causing the cushions to prolapse and the blood vessels to engorge. They are classified by grade based on their behavior:

Internal hemorrhoids originate above the dentate line (the anatomical border inside the anal canal) and are typically painless in lower grades. They are graded I–IV:

• Grade I: Bleed during defecation but do not prolapse. The patient experiences bright red blood on the tissue paper or coating the stool but no pain or tissue protrusion.
• Grade II: Prolapse (come out) during straining but return spontaneously when straining stops.
• Grade III: Prolapse during straining and require manual reduction back inside with a finger.
• Grade IV: Permanently prolapsed outside the anal canal. Cannot be reduced. May become thrombosed (clotted), causing severe pain.

External hemorrhoids develop outside the dentate line, in the perianal skin. They are covered by pain-sensitive skin and cause significant discomfort, particularly when thrombosed (acute perianal hematoma).

What Non-Surgical Treatments Are Available for Hemorrhoids?

Most Grade I and Grade II hemorrhoids respond to non-surgical treatment. Surgery is not the first step.

Dietary and lifestyle modification:

The cornerstone of hemorrhoid treatment and prevention. Constipation and prolonged straining are the primary drivers of hemorrhoid disease.

• Increase dietary fiber: Aim for 25–35 grams per day. Nepali dietary fiber sources: whole grain rice (kodo, marsi), lentils (mas, musuro), vegetables, green leafy saag, fruit. Commercial ispaghula husk (Isabgol/Sat Isabgol) is an effective fiber supplement.
• Adequate fluids: 2–3 litres of water daily prevents hard stool.
• Avoid straining: Do not spend more than 3–5 minutes on the toilet. Reading on the toilet prolongs straining time.
• Avoid prolonged sitting: Particularly in office workers and long-distance travelers.
• Sitz baths: Sitting in warm (not hot) water for 15–20 minutes after defecation, 2–3 times daily, reduces anal sphincter spasm and promotes blood return from engorged hemorrhoids.

Rubber band ligation (banding):

An elastic band is placed around the base of an internal hemorrhoid above the dentate line, cutting off its blood supply. The hemorrhoid shrivels and falls off in 3–5 days. Performed as an outpatient procedure, takes 2–3 minutes per hemorrhoid, and causes minimal discomfort (a sensation of fullness or mild ache for 24–48 hours). Effective for Grade I–III hemorrhoids. Up to 3 bands can be placed per session.

Sclerotherapy (injection):

A chemical solution (phenol in almond oil, or sodium tetradecyl sulfate) is injected into the hemorrhoid, causing fibrosis and reduction. Suitable for Grade I–II bleeding hemorrhoids. Less effective than banding for prolapsing hemorrhoids.

Which Grade of Hemorrhoids Requires Surgery?

Grade III hemorrhoids that fail rubber band ligation or are too large for banding may require surgical hemorrhoidectomy. Many Grade III hemorrhoids are successfully managed with banding.

Grade IV hemorrhoids almost always require surgical treatment as they cannot be reduced and do not respond to banding.

Acutely thrombosed external hemorrhoids causing severe pain may benefit from early surgical excision (within 48–72 hours of onset) to remove the clot and provide rapid pain relief. After 72 hours, conservative treatment (pain relief, sitz baths, topical treatment) is often preferable as the thrombosis begins to resorb spontaneously.

Strangulated prolapsed hemorrhoids — all four grades permanently out with impaired blood supply — require urgent surgical treatment.

What Surgical Options Are Available for Piles at A&B?

Conventional hemorrhoidectomy (Milligan-Morgan or Ferguson technique):

The hemorrhoid tissue is excised under anesthesia, removing the engorged vascular piles and the supporting tissue. The wounds may be left open (Milligan-Morgan — conventional in South Asia) or closed with absorbable sutures (Ferguson technique).

• Performed under spinal or general anesthesia as a day case or with one overnight stay.
• Definitive treatment — cure rates above 95%.
• Post-operative pain is the main drawback — the perianal area is highly sensitive. Adequate analgesia, stool softeners, and sitz baths are essential.
• Wound healing takes 2–4 weeks for open technique.

Stapled hemorrhoidopexy (Procedure for Prolapse and Hemorrhoids — PPH):

A circular stapling device is inserted to excise a ring of mucosa above the hemorrhoids, drawing the prolapsed tissue back into the anal canal and disrupting the blood supply to the hemorrhoids simultaneously.

• Advantages: Dramatically less post-operative pain than conventional hemorrhoidectomy (operation is performed above the pain-sensitive dentate line), faster return to work (3–7 days vs 2–4 weeks), quicker procedure.
• Disadvantages: Higher recurrence rate than conventional hemorrhoidectomy for Grade IV disease, requires specialized stapling device (additional cost), not suitable for external hemorrhoids.
• Best suited for: Grade III–IV internal hemorrhoids without significant external component.

How Is Post-Operative Pain After Hemorrhoid Surgery Managed?

Post-hemorrhoidectomy pain is the most significant issue following conventional hemorrhoidectomy. Pain peaks on days 2–4 and gradually improves over 2–3 weeks.

Pain management strategies:

• Scheduled analgesia: Paracetamol (1 g four times daily) plus ibuprofen (400 mg three times daily with food) as a baseline, with opioid analgesia (tramadol, dihydrocodeine) for breakthrough pain in the first week.
• Stool softeners: Lactulose or ispaghula husk prevents hard stool, which causes painful defecation. The first bowel movement post-operatively is dreaded by patients — softeners are essential.
• Sitz baths: Warm water soaks after each bowel movement dramatically reduce sphincter spasm and provide significant pain relief.
• Topical anesthetic: Lidocaine gel applied topically before anticipated defecation reduces pain.
• Avoiding constipation: Hard stool is the enemy of anorectal wound healing.

What Dietary Changes Prevent Hemorrhoids from Recurring?

After surgical treatment, hemorrhoids can recur if the underlying dietary and lifestyle causes are not addressed.

Permanent dietary changes for hemorrhoid prevention:

• High-fiber diet: The most important prevention measure. Traditional Nepali foods high in fiber include whole grain cereals (kodo, maize), legumes (all varieties of dal, black-eyed peas, chickpeas), vegetables (bitter gourd, drumstick, spinach), and fruits (guava, papaya, banana).
• Adequate hydration: Fiber without fluid causes impacted, hard stool. 2–3 litres of water daily.
• Avoid spicy food in excess: Capsaicin and other irritants may worsen anorectal discomfort during acute flares, though their role in causing hemorrhoids is limited.
• Avoid prolonged toilet sitting: The most underrated habit change.
• Regular physical activity: Sedentary lifestyle increases constipation risk.

Recovery timeline after piles surgery:

• Days 1–3: Rest, pain management, sitz baths, stool softeners.
• Week 1–2: Light activity. Many patients return to office work at 1 week (stapled) or 2 weeks (open).
• Week 3–4: Wound healing progresses. Physical labor typically resumed at week 4–6.
• Full healing: 6–8 weeks for open hemorrhoidectomy wounds.

Hemorrhoid Treatment at A&B International Hospital, Pokhara

A&B International Hospital

Pokhara-02, Bindhyaabasini Way to Sarangkot

Phone: +977 061-412512

Website: abinthospital.com

Non-surgical and surgical treatment for all grades of hemorrhoids. Rubber band ligation, conventional hemorrhoidectomy, and stapled hemorrhoidopexy. ECHS empanelled. Confidential consultations. Do not delay — call or book an appointment today.