Adequate dietary fiber supplement and TONE can help avoid surgery in most patients with advanced hemorrhoids.
BACKGROUND
The root cause of hemorrhoids resides in three deranged defecation habits (DDH), namely increased straining, prolonged defecation-time, and frequent bowel-motions. These DDH are responsible for the development of new hemorrhoids, progression of existing one and hemorrhoidal rupture (bleeding). DDH can be corrected with the help of the "TONE" mnemonic. TONE entails specifying exact treatment goals: T, three minutes at defecation; O, once-a-day defecation frequency; N, no straining during passing motions; E, enough fiber. TONE can be implemented by proper counseling and by prescribing fiber supplement appropriately (5-6 teaspoonfuls of psyllium husk with 600 mL of water daily. Corrected DDH would prevent the progression of hemorrhoids and bleeding episodes. An office procedure may be done to further downgrade the hemorrhoids.


METHODS
Patients with advanced hemorrhoids (grades III and IV) who were referred for surgery were prescribed fiber supplement and were counseled to follow TONE. The outcome parameters evaluated were improvement in prolapse, bleeding episodes, satisfaction levels.


RESULTS
A total of 102 patients (75 males and 10 females, mean age 46.0±13.5 years, 17 lost to follow-up) with advanced hemorrhoids (41 with early grade III, 38 with late grade III, and 6 with grade IV) were included in the study. All patients had symptoms of prolapsed hemorrhoids and bleeding episodes were present in 71.8% (61/85) of patients. After the follow-up of 40 (12-96) months, 68.2% (58/85) patients were highly satisfied, 12.9% (11/85) were moderately satisfied and 18.9% (16/85) were not satisfied with treatment. Prolapse improved in 56.5% (48/85), did not progress over time in 25.9 (22/85) and continued to progress in 4.7% (4/85) patients. 12.9% (11/85) underwent operation for hemorrhoids. Bleeding episodes decreased from 71.8% (61/85) to 29.4% (25/85) (P<0.0001).


CONCLUSIONS
Adequate fiber supplement combined with the TONE method can correct DDH, thus stopping the progression of hemorrhoids and bleeding, and preventing surgery in most patients with advanced hemorrhoids.
Colorectal Surgery Division, Department of General Surgery, Indus Super Specialty Hospital, Mohali, Punjab, India - drgargpankaj@yahoo.com.|Garg Fistula Research Institute, Panchkula, Haryana, India - drgargpankaj@yahoo.com.
Pankaj
P
Garg
Department of Public Health, University of North Texas Health Science Center, Fortworth, TX, USA.
Pratiksha
P
Singh
D000328:Adult; D003672:Defecation / Q000187:drug effects; D004043:Dietary Fiber / Q000008:administration & dosage*; D018450:Disease Progression; D005260:Female; D005769:Gastrointestinal Motility / Q000187:drug effects; D006484:Hemorrhoids / Q000175:diagnosis / Q000178:diet therapy* / Q000209:etiology / Q000628:therapy; D006801:Humans; D008297:Male; D008875:Middle Aged; D010353:Patient Education as Topic; D016896:Treatment Outcome
D004043:Dietary Fiber