**6.2 Calcium dobesilate**

It is an oral drug that has a venotonic effect (strengthens veins), reduces capillary permeability, inhibits thrombotic aggregation, and increases blood viscosity, which results in reducing edema. Calcium dobesilates are often used for leg varicose veins and diabetic retinopathy. Research on hemorrhoids using calcium dobesilate combined with fiber supplementation has also shown good clinical effects, namely reducing bleeding and inflammation [2].

#### **6.3 Topical treatment**

Forms of topical treatment of hemorrhoids are zalf, cream, or rectal suppositories. The purpose of topical treatment is to reduce the symptoms, so most of the ingredients are local anesthetics, corticosteroids, antibiotics, and anti-inflammatory drugs. There is not yet sufficient scientific evidence to support the use of topical treatment [8]. This drug can be purchased without a prescription. It is important to remember that topical treatments are only used in the acute stage. Long-term use of topical treatment can result in thinning the mucosa so that it bleeds easily or the possibility of fungal growth. It is highly recommended that after the acute stage has passed, the drug should be stopped and other drugs given orally, such as the flavonoids described above, should be continued zalf containing 0.2% glyceryl trinitrate or nifedipine, a calcium channel blocker, has been reported to reduce pain due to relaxation of the internal anal sphincter. There is also a topical vasoconstrictor, namely zalf, which contains 0.25% phenylephrine and is reported to reduce the complaints of hemorrhoid patients [19].

#### **6.4 Instrumentation**

In the early stages of hemorrhoids, instrumentation can be performed in the private practice room, so it is called an "office-based procedure." External hemorrhoids with thrombus—the thrombus can be removed under local anesthesia, while internal hemorrhoids can be performed with instrumentation. There are various types of instrumentation therapy, but the principle of action is the same. By performing fibrotization at the base of hemorrhoid, it is expected that the blood flow to the anal cushion will decrease and the prolapsed anal cushion will be shrunk and attracted cranially [2, 3].

#### **6.5 Thrombectomy**

Thrombectomy is the procedure of removing a thrombus (blood clot) from external hemorrhoid with a thrombus, performed under local anesthesia (**Figure 6a**). The pain of external hemorrhoids with thrombus occurs on the first day, and after the third day, the pain will decrease. Removing the thrombus will quickly relieve the pain. After the 3rd day, because the pain has subsided, there is no indication of thrombectomy. External hemorrhoid will heal through fibrotization of the thrombus into a skin tag [20].

#### **6.6 Sclerotherapy**

Submucosal injection at the base of hemorrhoid (**Figure 6b**) with sclerosing agents, such as 5% phenol in oil, vegetable oil, quinine, urea hydrochloride, and hypertonic saline, will result in fibrotization at the base of hemorrhoid so that the

**Figure 6.**

*Office-based procedure a. External hemorrhoid with thrombus, before and after excision b. Sclerotherapy c. Rubber Band Ligation. (illustrated by Kanaya).*

anal cushion will be retracted cranially. Injections are often needed several times until the anal cushion is in a normal position. Sclerotherapy is indicated in grade I, and II hemorrhoids [3]. The correct injection should be perivasal. Injection errors may cause problems. Too superficially, they may cause ulceration. Too deep into the muscle causes pain and possibly strictures. Injections into the plexus venosus can cause upper abdominal or precordial pain. Too deep into the prostate can result in an abscess and damage the periprostatic nerves, which can cause erectile dysfunction. Or it can be as serious as retroperitoneal sepsis, as reported by Barwell et al. (1999) [21]. Prophylactic antibiotics are not needed for sclerotherapy, except for cases with immunodeficiency [1–3].
