What are the treatment suggestions for a 23-year-old patient with hemorrhoids?

From the Guidelines

For a 23-year-old with hemorrhoids, I strongly recommend starting with conservative measures, prioritizing non-operative management as the first-line therapy, with dietary and lifestyle changes, as suggested by the most recent guidelines 1.

Key Recommendations

• Increase fiber intake to 25-30g daily and drink plenty of water (8-10 glasses daily) to soften stool and reduce straining during bowel movements.
• Avoid straining during bowel movements and practice good bathroom habits.
• Consider over-the-counter treatments such as topical creams containing hydrocortisone 1% (apply thin layer to affected area up to 3-4 times daily for no more than 7 days) to reduce inflammation and pain.
• Witch hazel pads or Preparation H can provide relief from itching and discomfort.
• Warm sitz baths for 10-15 minutes, 2-3 times daily, especially after bowel movements, can soothe the area.
• For pain, acetaminophen (up to 1000mg every 6 hours, not exceeding 4000mg daily) is preferable to NSAIDs, which may cause gastrointestinal irritation.

Important Considerations

• If symptoms don't improve within 1-2 weeks, or if there's significant bleeding, severe pain, or prolapse that won't reduce, medical evaluation is necessary.
• Hemorrhoids often result from increased pressure in the rectal veins due to constipation, prolonged sitting, or straining, so addressing these underlying causes is essential for long-term management and prevention.
• The use of flavonoids may be suggested to relieve symptoms, as indicated by moderate quality evidence 1.
• Topical muscle relaxants may be considered for thrombosed or strangulated hemorrhoids, although the evidence is of low quality 1.

From the FDA Drug Label

Ask a doctor before use if you have • abdominal pain, nausea or vomiting • a sudden change in bowel habits persisting for 2 weeks Stop use and ask a doctor if • constipation lasts more than 7 days • rectal bleeding occurs • you fail to have a bowel movement These may be signs of a serious condition.

For a 23-year-old with hemorrhoids, psyllium (PO) may be considered as a treatment option to help soften stool and reduce strain during bowel movements. However, it is essential to consult a doctor before use, especially if the patient experiences abdominal pain, nausea, vomiting, or rectal bleeding 2. The patient should also be aware of the potential signs of a serious condition, such as constipation lasting more than 7 days or failure to have a bowel movement 2.

• The patient can start with 1 dose per day and gradually increase to 3 doses per day as necessary.
• It is crucial to mix the product with at least 8 ounces of water or other fluid and stir briskly to avoid thickening 2.

From the Research

Treatment Options for Hemorrhoids

• Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the first line of treatment for hemorrhoids 3
• Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also help alleviate symptoms 3
• For internal hemorrhoids, rubber band ligation is a preferred office-based treatment, especially for grades I to III, due to its lower failure rate compared to infrared photocoagulation 3

Surgical Interventions

• Open or closed excisional hemorrhoidectomy can lead to greater surgical success rates but may result in more pain and a prolonged recovery 3
• Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain 3
• Stapled hemorrhoidopexy can elevate grade III or IV hemorrhoids to their normal anatomic position but has potential postoperative complications 3
• Hemorrhoidal artery ligation may be useful for grade II or III hemorrhoids, as it can result in less pain and quicker recovery 3, 4

Specific Considerations

• Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 3
• For high-graded internal hemorrhoids or when non-operative approaches have failed, surgery may be indicated 4
• Minimally invasive operations, such as Ligasure hemorrhoidectomy and doppler-guided hemorrhoidal artery ligation, have been introduced to reduce post-hemorrhoidectomy pain 4