For most proctological and general surgical conditions, treatment starts with conservative, meaning non-surgical, methods: diet, fluid intake, medication prescribed by your doctor, sitz baths and exercises. The choice between surgical and conservative treatment depends on the diagnosis, the stage of the disease and any complications. For some conditions, such as an anal abscess, surgery is the first and only right option.
Dr. Ellada Manafova is a female proctologist and general surgeon in Baku who sees patients at Qafqaz Hospital. Our approach is simple: first an accurate diagnosis, then treatment. Surgery is offered only when it is truly needed. If you have several problems at once, we also discuss the option of treating them in a single session.
What do conservative and surgical treatment mean?
Conservative treatment is treatment without surgery. Its aim is to ease symptoms, stop the disease from progressing and act on the cause, such as constipation. Surgical treatment removes the source of the problem: a hemorrhoid is removed, an abscess is opened, a weakened wall is repaired.
The choice depends on several factors:
- the diagnosis and the stage of the disease;
- how long the symptoms have lasted and whether conservative treatment has worked;
- whether there are complications: bleeding, inflammation, pus;
- your general health and any other conditions you have;
- your life plans, for example, plans for a pregnancy.
Which treatment for which condition?
The table below gives a general overview. The specific decision is made after an examination.
| Condition | Conservative treatment | When surgery is recommended |
|---|---|---|
| Hemorrhoids, grade I–II | enough in most cases | when bleeding and the piles persist despite treatment; for grade II, usually laser treatment (LHP) |
| Hemorrhoids, grade III–IV | gives only temporary relief | often: for grade III, laser (if the piles are not too large) or the Longo procedure; for grade IV, removal of the piles, for example with LigaSure |
| Anal fissure, acute (up to 6–8 weeks) | heals it in most cases | rarely |
| Anal fissure, chronic | medication can be tried first | when medication does not help: lateral internal sphincterotomy (LIS) or sphincter-sparing methods; the choice depends on the condition of the sphincter |
| Anal abscess (paraproctitis) | not enough: antibiotics do not cure an abscess | always: urgent incision and drainage |
| Anal fistula | a fistula does not heal on its own | always surgical; the method is chosen according to the type of fistula, and sphincter function is preserved |
| Rectocele, grade I, few symptoms | fiber, water, treating constipation, pelvic floor exercises | usually not needed |
| Rectocele, grade II–III, with symptoms | may not fully help | when difficulty emptying the bowel persists: posterior colporrhaphy, levatorplasty |
| Stress urinary incontinence | pelvic floor exercises, a pessary in some cases | when it persists despite the exercises: TOT (sling) procedure |
| Gallstones, no symptoms | usually monitoring | in some cases, for example when there is a gallbladder polyp of 1 cm or larger |
| Gallstones, with symptoms | medication usually does not get rid of the stones; it only eases attacks of colic | laparoscopic cholecystectomy |
| Lipoma | monitoring, if it is small and causes no symptoms | if it grows, hurts or bothers you |
Urinary leakage that comes with a sudden, overwhelming urge (urge incontinence) has a different mechanism, and a sling procedure does not treat it. That is why the type of incontinence is determined first.
What does conservative treatment include?
- Diet and fluids. High-fiber foods (vegetables, fruit, whole grains, bran) and enough water soften the stool and reduce straining. More: 5 golden rules against constipation.
- Medication, only as prescribed by a doctor. Stool softeners, ointments and suppositories help when they are chosen correctly. A product you pick up at the pharmacy on your own, however, can sometimes mask the signs of a serious disease and delay treatment.
- Sitz baths. Warm water eases spasm and pain in the anal area, especially with an anal fissure or hemorrhoids.
- Pelvic floor exercises. These are the main non-surgical method for urinary incontinence, a mild rectocele and weakness after childbirth. Results are felt after several months of regular exercise. Step-by-step instructions are in our article on problems after childbirth.
- Pessary. A soft supportive ring placed in the vagina. It can help women with a sagging bladder or other pelvic organs who do not want surgery or are not ready for it yet. The doctor shows you how to insert and remove it.
- Changing habits. Not sitting on the toilet for long with your phone, not straining, not holding back the urge, moving more, lifting heavy things correctly and quitting smoking.
Conservative treatment does not mean “doing nothing”: it is planned, monitored treatment. Its results are assessed at a follow-up visit. If it does not help, the plan is changed.
What principles guide surgical treatment?
- As little trauma as possible. Whenever possible, minimally invasive methods are chosen: laser for hemorrhoids and anal fissures, the LigaSure device that seals blood vessels for hemorrhoids, and laparoscopy through small incisions for the gallbladder.
- Protecting the sphincter. The anal sphincter, the ring of muscle that closes the anus, is responsible for holding in gas and stool. In anal fissure and fistula surgery, the method is chosen so that the sphincter's ability to hold is preserved.
- The right method for each patient. The same method does not suit every stage. For example, laser may not be suitable for very large hemorrhoids that have prolapsed outside.
- Anesthesia is chosen individually. Minor procedures are often done under local anesthesia, others under spinal anesthesia (numbing of the lower half of the body) or general anesthesia. The type is chosen together with the anesthesiologist, based on the operation, its duration and your health.
- Pain under control. After surgery, pain is managed with painkillers, and your diet is set up so that the first bowel movement is soft.
Preparing for surgery
Before surgery, blood tests and other necessary checks are done, and the anesthesiologist meets with you. Be sure to tell us about any medications you take, especially blood thinners, as well as any chronic conditions and allergies. You will receive exact instructions about fasting and your medications before the operation.
Combined (“bouquet”) surgery: one anesthetic, several solutions
A “bouquet” operation means that several procedures a patient needs are done in one session, under a single anesthetic. The medical terms are combined or simultaneous surgery; we simply call it a “bouquet.”
Having several problems at once is often no coincidence. The same cause — for example, difficult childbirths or years of constipation — can affect several organs. And a rectocele that forces you to strain for years increases the risk of hemorrhoids and anal fissures.
Which operations can be combined?
Anonymized examples from our practice:
- hemorrhoids and rectocele;
- rectocele, vaginoplasty and labiaplasty;
- rectocele, labiaplasty, and removal of hemorrhoids and polyps;
- urinary incontinence surgery, rectocele, hemorrhoids and an anal fissure;
- gallbladder removal and an anal fissure;
- gallbladder removal, an umbilical hernia and abdominoplasty (a tummy tuck).
In our practice, a combination of four operations has taken about 1 hour 15 minutes, and a combination of five or six operations 2–2.5 hours. Your exact duration will be given after the examination. You can read more about treating problems after childbirth together on the vaginoplasty page.
Advantages
- one anesthetic: no need to go under anesthesia several times;
- one round of preparation and one hospital stay;
- one recovery period: you take time away from work and family only once;
- treatment is not spread over months: the problems are treated at the same time.
For many patients, the most important thing is going through recovery only once.
Limitations and safety
Combined surgery is not for everyone. The surgeon makes the decision together with the anesthesiologist, after tests and an examination. The following are taken into account:
- your general health and age;
- chronic conditions of the heart or lungs, diabetes and blood clotting problems;
- the total length of the operations: the longer the anesthesia, the higher some risks become, such as the risk of blood clots forming in the vessels;
- expected blood loss;
- whether the operations are compatible: for example, a planned aesthetic procedure is postponed if there is an acute inflammation with pus.
If the risks outweigh the benefits, the operations are done in stages, at separate times. If something unexpected comes up during surgery, part of the plan may be postponed. After combined surgery, the first few days may be a little harder than after a single operation, and the hospital stay may be slightly longer.
What to expect after surgery
Pain is kept under control with painkillers, and getting up and moving early is recommended. Your diet is set up to keep the stool soft, which is especially important after proctological and pelvic floor surgery. How long you stay in the hospital depends on the type of operation: after some minor procedures you go home the same day, while after combined surgery the stay may be a bit longer. Your return to work and follow-up visits are planned individually; the exact timeline is given after the examination.
Frequently asked questions
Does every case of hemorrhoids or anal fissure need surgery?
No. Early-stage hemorrhoids and an acute anal fissure heal without surgery in most cases — with diet, changes in toilet habits and medication prescribed by a doctor. Surgery is offered when the disease has progressed or conservative treatment has not helped.
How long should conservative treatment last?
It depends on the condition. With an acute anal fissure, the result usually becomes clear within 6–8 weeks, while pelvic floor exercises need several months. It is important to come for a follow-up visit during this time: if there is no improvement, the plan is changed.
Can I buy an ointment at the pharmacy and use it on my own?
We do not recommend it. Pain, blood or a lump at the anus does not always mean hemorrhoids: a fissure, a polyp, a fistula and, rarely, a tumor can cause similar symptoms. Treatment without a diagnosis wastes time and can hide the real problem.
Is combined surgery dangerous?
Every operation carries risks, and combined surgery is no exception. In a carefully selected patient, when it is planned after tests and together with the anesthesiologist, several operations can be combined safely. If the risks outweigh the benefits, the operations are done separately. The decision is always based on your state of health.
How many operations can be done in one session?
There is no fixed number. In our practice, between two and six operations have been combined in one session. The number depends on your general health, the extent of the operations and the total duration.
What kind of anesthesia will be used?
It depends on the operation and your health. Minor procedures are done under local anesthesia, others under spinal or general anesthesia. The type is chosen together with the anesthesiologist before surgery and discussed with you.
What is recovery like after combined surgery?
The first few days may be a little harder than after a single operation, but you go through recovery only once. Pain is kept under control with painkillers. Your return to daily life depends on which operations were combined and is planned individually.
Medically reviewed by: Dr. Ellada ManafovaLast updated:
The information on this page is for education only and does not replace an examination by a doctor. If you have symptoms, book an appointment. In an emergency, call 103.