What evidence is there for using hyaluronidase for acute hemorrhoidal crisis?

What evidence is there for using hyaluronidase for acute hemorrhoidal crisis?

Comment by InpharmD Researcher

Evidence supporting hyaluronidase for acute hemorrhoidal crisis is limited, with most data derived from dated case reports involving acute prolapsed, edematous, or incarcerated hemorrhoids. The available reports describe hyaluronidase combined with local anesthetic and epinephrine, with reductions in hemorrhoidal edema that facilitated reduction of prolapsed hemorrhoids and/or subsequent surgical treatment. Guidelines do not specifically address hyaluronidase for complicated hemorrhoids and state that available evidence is insufficient to make a recommendation regarding local anesthetic injections. Overall, available evidence suggests potential utility for hyaluronidase in acute hemorrhoidal crisis, but its role remains uncertain given the lack of high-quality comparative evidence.

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Background

The World Society of Emergency Surgery-American Association for the Surgery of Trauma (WSES-AAST) 2021 guidelines on anorectal emergencies do not specifically address or provide recommendations regarding hyaluronidase for complicated hemorrhoids. They state that no recommendation can be made regarding injection of local anesthetics for complicated hemorrhoids based on the available literature. Hyaluronidase is mentioned separately as a nonoperative technique to reduce edema in incarcerated rectal prolapse. [1]

A 2011 clinical review of hemorrhoidal disease described hyaluronidase as part of an office-based treatment approach for acute hemorrhoidal disease with strangulation, involving incarcerated prolapsed internal hemorrhoids with progressive edema and associated thrombosed external hemorrhoids. The approach involved a local block and direct injection with 0.25% bupivacaine with epinephrine 1:100,000 mixed with hyaluronidase. Hyaluronidase was described as increasing tissue permeability, enhancing local anesthetic dispersion, and decreasing hemorrhoidal edema and swelling, allowing reduction of the internal hemorrhoids along with sphincter relaxation from the local block. Internal hemorrhoid ligation and excision of the external thromboses were subsequently performed. The authors noted that hemorrhoidal disease should be managed individually based on the type and severity of symptoms and the patient’s other medical conditions. [2]

Literature Review

A search of the published medical literature revealed 5 studies investigating the researchable question:

What evidence is there for using hyaluronidase for acute hemorrhoidal crisis?

Level of evidence

D - Case reports or unreliable data Read more→

Please see Tables 1-5 for your response.

Treatment of acute hemorrhoidal crisis using hyaluronidase with local anesthetic prior to surgical excision
Design	Case report
Case presentation	A patient with acute hemorrhoidal crisis received a perianal injection of 20 mL of 0.25% bupivacaine with epinephrine 1:100,000 and 150 IU of hyaluronidase, with an additional 10 mL injected into the hemorrhoidal bundles. The three hemorrhoidal bundles were reduced into the anal canal and pressure was applied for 5 minutes, after which a significant reduction in hemorrhoidal disease was observed. A gangrenous right anterior hemorrhoid was excised, while the smaller right posterior and left lateral bundles were treated with suture ligation and hemorrhoidopexy. The patient was discharged on postoperative day 3 without excessive bleeding or fecal or urinary incontinence. The authors concluded that adding hyaluronidase to local anesthetic and epinephrine before surgical treatment was a safe and effective method for facilitating resolution of perianal edema and enhancing the surgical technique.
Study Author Conclusions	The use of hyaluronidase as an adjunct to standard local anesthetic and epinephrine prior to surgical treatment of hemorrhoidal crisis is a safe and effective method to facilitate the resolution of perianal edema and to enhance surgical technique.

Table 1 References:
[3] Kolbe N, Hain J. Treatment of acute hemorrhoidal crisis using hyaluronidase with local anesthetic prior to surgical excision. Tech Coloproctol. 2015;19(8):487-488. doi:10.1007/s10151-015-1339-9

The Outpatient Management of Acute Hemorrhoidal Disease
Design	Case series
Case presentation	Patients presenting with acute hemorrhoidal disease were treated using an outpatient approach involving perianal and submucosal infiltration of 0.25% bupivacaine with epinephrine 1:200,000 and hyaluronidase (150 units per 10 mL of anesthetic solution). Pain relief was reported as immediate, and massage and manual compression were used to dissipate edema and allow complete reduction of the hemorrhoidal mass. Internal hemorrhoids were subsequently treated with rubber band ligation, and external thromboses, when present, were treated with thrombectomy. The authors reported that hospitalization was avoided, subsequent hemorrhoidectomy was rarely required, and no significant anal stenosis or perioperative hemorrhage occurred.
Study Author Conclusions	Treatment, using local anesthesia with hyaluronidase, is directed to (1) relieve pain, (9) decrease edema, (3) treat appropriately the internal hemorrhoidal disease, and (4) treat the external thrombosis if present. Adequate treatment of the acute disease will, in a significant proportion of patients, avoid further surgical intervention. Experience with results of this modality of treatment in patients is presented.

Table 2 References:
[4] Eisenstat T, Salvati EP, Rubin RJ. The outpatient management of acute hemorrhoidal disease. Dis Colon Rectum. 1979;22(5):315-317. doi:10.1007/BF02609314

Hyaluronidase with Local Anesthesia in Anorectal Surgery
Design	Case series
Case presentation	A total of 357 hospitalized patients underwent anorectal surgery under local anesthesia using a solution containing hyaluronidase. The solution was prepared with 300 TR units of hyaluronidase in 40 mL of 1% procaine with 0.3 mL of epinephrine 1:1,000, with approximately 18–25 mL of the solution used per operation. In patients with substantial pre-existing perianal edema, hyaluronidase was reported to result in complete disappearance of the edema within 30 seconds after injection, allowing improved operative technique, less tissue trauma, and avoidance of excessive skin excision; the authors also reported that this allowed earlier surgery in patients with hemorrhoidal prolapse and marked edema.
Study Author Conclusions	The use of hyaluronidase enhances the efficiency of local anesthesia in anorectal procedures. As clinical experience with the described method increases, it is becoming clear that hyaluronidase merits more general use in anorectal surgery.

Table 3 References:
[5] Schneider HC. Hyaluronidase with local anesthesia in anorectal surgery. Am J Surg. 1954;88(5):703-706. doi:10.1016/0002-9610(54)90260-3

Hyaluronidase in Local Anesthesia for Severe Hemorrhoids and Procidentia
Design	Case series
Case presentation	A total of 2,788 patients undergoing anorectal surgery received local anesthesia with hyaluronidase over 7 years, using various anesthetic agents and concentrations of epinephrine and hyaluronidase. One regimen consisted of 300 units of hyaluronidase with 1% lidocaine and epinephrine 1:100,000 in 50 mL of saline. For large prolapsed edematous hemorrhoids, generally 10–20 mL was infiltrated subcutaneously around the rectal outlet, with the internal prolapsed area similarly injected. By the end of infiltration, hemorrhoidal edema decreased to approximately one-tenth of its original size, after which the hemorrhoids were surgically removed with very little bleeding.
Study Author Conclusions	The value of local anesthesia with hyaluronidase in operations on the anal canal and lower rectum is pointed out, and particular emphasis is made of its effect upon hemorrhoidal edema. The relative safety of this type of local anesthesia for more formidable operative procedures such as perineal resection and repair of levator musculature for rectal procidentia is discussed. Muscle relaxation is excellent, even though direct infiltration into the anal sphincters and levator ani muscles is not needed. The instantaneous action of the anesthetic agent is striking. We believe that the two patients with procidentia would not have done well under general anesthesia. Local anesthesia made possible the successful correction of debilitating rectal prolapses.

Table 4 References:
[6] Zamborsky EJ, Trimpi HD. Hyaluronidase in Local Anesthesia for Severe Hemorrhoids and Procidentia. Dis Colon Rectum. 1963;6:411-414. doi:10.1007/BF02633476

EP249 - Use of Hyaluronidase with Local Anesthetic in the Treatment of Grade IV Internal Hemorrhoids
Design	Case series
Case presentation	A 54-year-old male with no prior hemorrhoid-related symptoms presented with 1 day of painful, prolapsed grade IV internal hemorrhoids, and a 30-year-old male with a history of grade III hemorrhoids presented with incarcerated grade IV internal hemorrhoids and thrombosed external hemorrhoids. Both patients received 150 TR units (1 mL) of hyaluronidase mixed with 30 mL of 0.25% bupivacaine with epinephrine 1:100,000, injected circumferentially into the edematous hemorrhoids and as a perianal block. Firm massage and pressure were applied for 5 minutes, resulting in resolution of edema and complete reduction of the prolapse in both patients. Both patients were discharged from the emergency department; at follow-up, the first patient had complete resolution without further intervention, while the second subsequently underwent elective transanal hemorrhoidal dearterialization.
Study Author Conclusions	The use of hyaluronidase mixed with local anesthetic is a safe and effective method to treat Grade IV hemorrhoids and manage an acute hemorrhoidal crisis. This allows resolution of perianal edema and reduction of hemorrhoids. Patients can then proceed to elective office-based interventions (i.e. sclerotherapy, rubber band ligation) or operative interventions.

Table 5 References:
[7] Mehrotra S, Wilkins SB, Notaro JR, et al. EP249 - Use of Hyaluronidase with Local Anesthetic in the Treatment of Grade IV Internal Hemorrhoids. Poster presented at: ASCRS Annual Scientific Meeting; May 10-13, 2025; San Diego, CA.