Sclerotherapy or Injection Therapy

What is Sclerotherapy?

Sclerotherapy is commonly used to treat bleeding internal hemorrhoid. In this procedure, a sclerosing or hardening solution (also called a sclerosant) is injected into the base of the hemorrhoids.

There are many types of sclerosants, including chemical (phenol in almond oil) and saline solutions, but they all do the same thing: they cause a low-grade, long-standing inflammation reaction which “scar” the vein and mucosal tissue, collapse the vein walls, and cause the hemorrhoids to shrivel.

Advantages & Disadvantages

The advantages of sclerotherapy include:

1. Easy and inexpensive to administer, can be used as an out-patient procedure
   
   The technique of sclerotherapy is simple to learn and it is not complicated to perform as an inexpensive out-patient procedure. No costly anesthesia or lengthy hospital stay required.
   
   
2. It works fast and last long
   
   Approximately 7 to 10 days after the procedure, the shriveled hemorrhoid should fall off during normal bowel movement. In general, the patient should then be symptoms free and does not suffer from bleeding hemorrhoid for at least 12 months.
   
   
3. Can be performed in elderly patients
   
   Sclerotherapy is usually the method of choice for treating small hemorrhoids in elderly patients, who have fragile veins.
   
   
4. Multiple hemorrhoids can be treated at once
   
   Typically, up to 3 hemorrhoids can be injected per treatment.

The disadvantages of this procedure include:

1. Large incidence of failure for larger hemorrhoids
   
   Because there is a high likelihood of failure of injection therapy for large hemorrhoids, and the availability of other treatment methods (such as rubber band ligation), sclerotherapy should not be used.
   
   
2. Hemorrhoid returns after treatment
   
   Sclerotherapy is not a cure for hemorrhoids. Piles can and do come back after being injected, although usually not within 12 months after the treatment.

Who Should Get Sclerotherapy?

Sclerotherapy should be used only for smaller hemorrhoids, such as first-degree and early second-degree piles.

First-degree piles, even those which are bleeding profusely, usually respond well to sclerotherapy (or in some cases, multiple treatments of sclerotherapy). However, other contributing causes for the bleeding, such as the use of aspirin or contraceptive pill, should first be stopped.

Second-degree hemorrhoid, in which the prolapse is slight or barely noticeable, also responds well to this procedure. However, as the hemorrhoid becomes larger, the chance of success becomes smaller and multiple injections may be necessary. In this case, either the initial treatment should consist of multiple injections or a follow-up treatment should be performed.

Who Should NOT Get Sclerotherapy?

Sclerotherapy should not be performed if the patient has:

1. Acute prolapse-thrombosis
   
   Third-degree hemorrhoids should not be treated with sclerotherapy, because the risk of acute prolapse-thrombosis - a complication where painful blood clots develop - is very high.
   
   Large second-degree hemorrhoids should also not be treated with this procedure, because the chance of success is not good.
   
   
2. Severe bleeding or ulceration
   
   Hemorrhoids that are accompanied by other ano-rectal conditions, such as inflammatory bowel diseases (Crohn’s disease and ulcerative colitis), sclerotherapy may cause severe bleeding or formation of ulcers in the colon’s mucosal tissue.
   
   
3. Fissures and fistula
   
   Anorectal conditions such as fissure and fistula-in-ano are contraindications to sclerotherapy.

Sclerotherapy Procedure

1. Preparation
   
   The patient should be advised to defecate shortly before the treatment, as passing stool shortly after the therapy may disperse the sclerotherapy solution and therefore reduce its effectiveness.
   
   The anal canal should be properly lubricated and local anesthetic gel is applied. In addition to preventing pain, the application of local pain killer can help reduce patient anxiety.
   
   
2. Position
   
   The patient is usually laid down on his or her left side in the left lateral position, with the buttocks projecting over the edge of the table.
   
   
3. Injection
   
   A proctoscope with a wide-bore is inserted into the anal canal to illuminate the hemorrhoid to be injected.
   
   Injection should be done at the base of the hemorrhoid, above the dentate line, where no or little pain should be felt. This is because the dentate line separates the insensitive columnar epithelium from the sensitive squamous epithelium below. If pain is felt when the needle pierces the tissue, it is likely that the injection site is incorrect.
   
   Once the correct injection site is located, the needle is inserted about 1 to 2 cm deep, parallel to the anal canal. About 3 to 5 ml of sclerosant is injected slowly, allowing time for dispersion in the tissue. While being injected, the patient should be asked whether pain is felt – if so, the injection should be stopped immediately.
   
   After the injection is complete, the needle should not be withdrawn immediately, since this may lead to bleeding and leaking of the sclerotherapy solution. Instead, the needle should be held in place for about two minutes, then slowly withdrawn to facilitate the sealing of the tract.
   
   In most patients, a maximum of three separate injections to the bases of the hemorrhoids are given.

When proper technique is employed, the patient should not experience more than mild ache or discomfort.

Complications

Serious complications from sclerotherapy are rare – they occur in only approximately 0.02% or 1 in 5,000 injections – and arise mostly from improper technique.

Possible complications include:

1. Bleeding
   
   Immediate bleeding may be caused by accidentally puncturing an artery and can almost always be stopped by immediate pressure using gauze.
   
   Delayed bleeding can be caused by too much solution being injected, or by wrongly injecting the mucosa layer instead of beneath it. This can cause an ulcer to develop and bleeding 7 to 14 days after the injection, requiring hospitalization.
   
   
2. Pain
   
   Although discomfort or aching is normal, real pain is not and is almost always caused by improper selection of injection site. Injection should be done above the dentate line, which separates the anus from the rectum. Sometimes, even though the injection site is correct, the sclerotherapy solution or sclerosant can spread below the dentate line into the sensitive tissues.
   
   Once pain is felt, the injection should be stopped immediately. Usually, the pain is short-lived and can be managed by topical pain killers.
   
   Aching and discomfort within the first 24 hours of injection are normal and can be managed by over the counter pain killers such as aspirin.
   
   
3. Injection into the vein
   
   If the solution appears to be injected too easily or if the patient notices pain in the liver area or unpleasant taste in the mouth, the needle has accidentally entered anal veins – injection should be stopped immediately.
   
   There is no harmful side effect of this complication, although since the sclerotherapy solution is dispersed through the body’s circulatory system, it should not be expected to be effective in dealing with the hemorrhoid.
   
   
4. Injection into the prostate
   
   Accidental injection into the prostate is possible, especially if the patient is a man suffering from enlarged prostate. It is also possible to accidentally inject into the vein that goes between the prostate and the rectal area.
   
   Depending on the amount of sclerosant that enters the prostate and the depth of penetration, the complications vary from relatively minor to very serious:
   
   
   • Retention of urine
     
     Here, the patient is unable to urinate. This is the most common (and minor) of complications from accidental injection into the prostate. Usually, the situation resolves by itself without medical intervention, although in some patients temporary insertion of a catheter tube to aid urination is required.
     
     
   • Infertility
     
     If the solution enters the seminal vessel and spread to the testicle and its tissues, withering of the testicles and infertility may occur.
     
     
   • Inflammation of the prostate glands (or prostitis)
     
     The symptoms of prostitis include partial incontinence, frequent urination, pain, burning sensation during urination, blood or pus in the urine. These symptoms may last weeks, months, or even years – and although antibiotics should be prescribed, there is no direct treatment for this complications.
     
     
   • Abscess formation
     
     A deep injection into the prostate can cause an abscess or a pus-filled inflammation in the prostate glands. This may require surgery by a urologist.
     
     
   • Painful blood clot formation
     
     If a large second-degree or third-degree hemorrhoid is improperly treated by sclerotherapy, very painful blood clots may be formed. This may require more radical procedures such as anal dilation or surgery.

After the Procedure

After a short period to recover, the patient can be sent home if there are no immediate bleedings. Mild aching and discomfort is common, and can be treated by pain killers – codeine should be avoided since it can cause constipation.

To avoid the injected solution from dispersing by straining to pass stool, the doctor may prescribe a lubricant suppository and a stool softener.

A follow-up appointment is usually set for three weeks after the treatment, at which time more injections may be necessary if the symptoms of the hemorrhoid are not resolved.