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Clinical Case Studies

Introduction
Thrombosed external hemorrhoids are a common anorectal condition characterized by the sudden onset of a painful, swollen perianal mass resulting from thrombosis of the external hemorrhoidal venous plexus. The condition causes significant acute pain, edema, and functional impairment, often prompting urgent medical visits.

Standard management ranges from conservative measures (fiber, topical analgesics, warm sitz baths) to office-based excision and thrombectomy. However, many patients experience incomplete relief or seek alternatives to invasive procedures. This article presents a clinical case in which hirudotherapy was used as an adjunctive treatment for acute thrombosed external hemorrhoids, resulting in rapid symptom resolution.

Clinical Case Presentation
A 45-year-old male presented with acute-onset severe perianal pain that began 48 hours earlier. The pain was exacerbated by sitting, walking, and defecation. Physical examination revealed a bluish, tense, swollen external hemorrhoidal thrombus approximately 1.5 cm in diameter at the left lateral position, with surrounding edema and erythema. The patient reported no prior history of hemorrhoidal disease, though he noted recent episodes of constipation and prolonged sitting during travel.

Conservative measures attempted prior to presentation included topical hydrocortisone cream, oral analgesics, and warm sitz baths, with minimal relief. The patient was offered office-based thrombectomy but expressed strong preference for a less invasive approach.

Treatment Approach
After informed consent and discussion of risks and benefits, the clinical team employed adjunctive hirudotherapy. Two medical-grade leeches (Hirudo verbana) were applied directly to the thrombosed hemorrhoidal mass and adjacent edematous tissue. The leeches were allowed to feed until spontaneous detachment, approximately 45 minutes.

Standard infection control measures were implemented, including perianal cleansing, post-application wound care, and a short course of prophylactic antibiotics targeting Aeromonas species. The patient was instructed to monitor for excessive bleeding and to follow up within 24 hours.

Clinical Outcome
Within hours after the procedure, the patient reported substantial reduction in pain and a sensation of “pressure release.” By the 24-hour follow-up, the thrombosed mass had decreased significantly in size, the bluish discoloration had faded, and perianal edema had visibly subsided. The patient was able to sit comfortably and resume normal activities.

Over the following week, complete resolution of the thrombus was observed, with no recurrence or complications at the one-month follow-up. The patient required no additional analgesics or further intervention.

Proposed Mechanisms of Action
The favorable outcome in this case can be attributed to several complementary effects of hirudotherapy:

Mechanical decompression: Direct blood withdrawal from the thrombosed venous plexus reduces intravascular pressure, alleviating pain and tissue tension.

Anticoagulation: Hirudin and other thrombin inhibitors prevent extension of the thrombus and promote natural recanalization.

Anti-inflammatory activity: Eglin and anti-stasin modulate local inflammation, reducing edema and secondary tissue damage.

Enhanced microcirculation: Local vasodilation and improved blood flow facilitate clearance of inflammatory mediators and support tissue healing.

In the context of acute hemorrhoidal thrombosis, these mechanisms address both the mechanical obstruction and the inflammatory component, providing rapid symptomatic relief without the need for surgical incision.

Safety Considerations and Limitations
Application of hirudotherapy in the anorectal region requires specific precautions:

Infection risk: The perianal area harbors a diverse microbiota; concurrent antibiotic prophylaxis is strongly recommended.

Bleeding: Prolonged oozing may occur; patients with coagulopathies or those on anticoagulants are generally not candidates.

Hygiene and follow-up: Proper application technique and post-procedural wound care are essential to prevent complications.

Not a substitute for surgical indications: Patients with large, strangulated, or infected hemorrhoids, or those with persistent bleeding, require appropriate surgical evaluation.

In this case, the patient was carefully selected—immunocompetent, with no coagulopathy, and with a discrete thrombus amenable to localized treatment.

Discussion
This case illustrates the potential utility of hirudotherapy as an adjunctive, minimally invasive option for acute thrombosed external hemorrhoids in patients seeking alternatives to office-based procedures. The rapid symptom relief and absence of complications align with the biological plausibility of leech therapy in conditions characterized by venous