TONEFACT: Can even advanced hemorrhoids be treated without surgery? A paradigm shift in the management of hemorrhoids

Table 1 Categorized description and benefits of TONEFACT regimen

Interventions	TONEFACT component	Description	Addresses causative factor
Behavioral	T-time during defecation	≤ 5 min during defecation	Prevents prolonged defecation time; defines objective endpoints of management[29,30]
Behavioral	O-once (frequency of defecation)	Defecation once daily, avoiding unnecessary multiple attempts	Prevents repeated straining; supports objective management endpoints[19]
Behavioral	N-no mobile or newspaper on toilet	Avoiding use of gadgets or reading material on the toilet	Prevents prolongation of defecation time[31-35]
Behavioral	C-compulsive defecation to be avoided	Avoiding defecation for non-physiological reasons (e.g., social pressure)	Prevents excessive straining and hemorrhoidal rupture/thrombosis[30]
Behavioral	T-to resist desire for 100% evacuation	Avoid unnecessary straining for complete emptying sensation	Prevents prolonged defecation and excessive straining
Exercise-based	E-exercise (Kegels)	100 daily Kegel exercises	Improves pelvic floor and anal muscle tone; reduces prolapse and mucus discharge[64,65]
Dietary	F-fiber and fluid intake	20–25 g psyllium husk + 500 mL water; total fluid ≥ 3.5 liters/day	Softens stool, reduces defecation time, improves bowel regularity[58]
Postural	A-apply pressure during defecation and keep a bench under feet	Use of a small bench under the feet to mimic the squatting position	Facilitates complete evacuation and reduces time/straining during defecation[59,60]