Objectivive To find out causes of thrombosed external hemorrhoids (TEH). Subjects and Methods Prospective cohort study of individuals with and without TEH with comparison of answers to a questionnaire. Results One hundred forty-eight individuals were enrolled, 72 patients with TEH and 76 individuals without TEH but with alternative diagnoses, such as a screening colonoscopy or colonic polyps. Six independent variables were found to predict TEH correctly in 79.1% of cases: age of 46 years or younger, use of excessive physical effort, and use of dry toilet paper combined with wet cleaning methods after defecation were associated with a significantly higher risk of developing TEH; use of bathtub, use of the shower, and genital cleaning before sleep at least once a week were associated with a significantly lower risk of developing TEH. Conclusions Six hypotheses on the causes of TEH should be considered in future studies on etiology and prophylaxis of TEH. Introduction Etiology of thrombosed external hemorrhoid (TEH) is unknown despite numerous hypotheses (1-7). There are two common clinical presentations of the disease: as a circular thrombosis of external hemorrhoids or as thrombosis of a single external pile occasionally with bleeding. We limited our study to single TEH using Hancock’s definition of “an acute localised thrombosis which may affect the external plexus” (8). Synonyms are acute thrombosed external hemorrhoid (2,9), acute hemorrhoidal disease (10), anal hematoma (11,12), perianal hematoma (13,14), thrombosed hemorrhoid (15), hemorrhoidal thrombosis (3,12), and perianal thrombosis (16). We were interested to learn more about causes of the disease since it is a common anorectal disorder (10,17,18,19), prophylaxis is needed and optimal therapy debatable. Subjects and Methods Research literatureWe searched the MEDLINE database (December 1958 to January 2004) using all synonyms for TEH. One hundred eighty-seven papers were collected. Papers were reviewed as well as journal reverence lists and standard textbooks, and we applied our existing knowledge in this area (21). Patients with and without TEHIndividuals of both genders, aged 16 – 80 years old, who entered consecutively into our office from March 18 2004, to August 18 2005 were enrolled referred from general practitioners, physicians, urologists or gynecologists for anal (i.e. pain, bleeding) and/or abdominal complaints (i.e. flatulence). Proctologic assessment in the knee-chest-position (21) included inspection of the perianal area, anoscopy and digital examination if possible.QuestionnairePatients with and without TEH completed a questionnaire that focused on published hypotheses of TEH etiology (table 1). Data from the questionnaires were collected, and the answers of patients with TEH were compared to those individuals without TEH.
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