Real-world use of polidocanol foam sclerotherapy for hemorrhoidal disease: insights from an international survey and systematic review with clinical practice recommendations

Polidocanol foam sclerotherapy has gained increasing attention as a minimally invasive treatment for hemorrhoidal disease (HD). However, significant variability exists in its clinical application regarding patient selection, procedural techniques, and postoperative management. This study aimed to assess real-world practice patterns among international experts, summarize existing evidence through a systematic literature review, and develop evidence-based clinical practice recommendations. A systematic review was conducted in MEDLINE, EMBASE, and CENTRAL to identify studies evaluating polidocanol foam sclerotherapy for HD. A total of 20 studies met the inclusion criteria. Additionally, an international survey was distributed to 30 experts in proctology and colorectal surgery to explore variations in indications, perioperative management, technique, and follow-up. Survey responses were analyzed descriptively to identify common trends and areas of divergence. Subsequently, based on both the experts’ opinions and the results of the survey, a Delphi method was employed to produce clinical practice recommendations. The questions for the Delphi process were developed by the authors leading the project, followed by a detailed discussion with the whole panel of experts. Most experts (90%) reported using polidocanol foam sclerotherapy primarily for Goligher grade II HD, with 67% extending its use to grade III cases. Preoperative bowel preparation and anesthesia use varied widely. The preferred concentration was 3% polidocanol, with 2 mL injected per hemorrhoidal pile in most cases. Post-procedural care lacked standardization, though stool softeners and flavonoids were commonly recommended. Compared to rubber band ligation, polidocanol foam was perceived as having higher success rates (88.3% vs. 66.7%) and lower recurrence rates (16.1% vs. 41.2%). Adverse events were infrequent. The present article offers a comprehensive suite of clinical practice expert-based recommendations concerning the use of polidocanol foam sclerotherapy for HD. However, there is still significant variation in its application. These findings highlight the need for standardized guidelines and further research to optimize procedural strategies and long-term outcomes.