From the Guidelines
Treatment for external hemorrhoids should prioritize a combination of home remedies and medical interventions, with a focus on conservative measures for mild to moderate cases and surgical options for severe or persistent cases, as suggested by the most recent guidelines 1.
Home Remedies and Conservative Measures
For mild to moderate external hemorrhoids, start with conservative measures like:
- Warm sitz baths for 10-15 minutes, 2-3 times daily to reduce swelling and discomfort
- Over-the-counter medications such as hydrocortisone cream (1%, applied sparingly to the affected area up to 4 times daily for no more than 7 days) to reduce inflammation and itching
- Witch hazel pads or medicated wipes containing witch hazel for cooling relief
- Oral pain relievers like acetaminophen (Tylenol, 500-1000mg every 4-6 hours, not exceeding 4000mg daily) or ibuprofen (Advil, 400-600mg every 6-8 hours with food) to manage pain Increasing fiber intake to 25-30g daily through diet or supplements like psyllium husk (Metamucil, 1 tablespoon in water 1-3 times daily), staying well-hydrated, and avoiding straining during bowel movements are crucial for preventing worsening of symptoms, as supported by earlier studies 1.
Medical Treatments
For severe or persistent external hemorrhoids, medical treatments may include:
- Rubber band ligation
- Sclerotherapy
- Infrared coagulation
- Surgical hemorrhoidectomy These treatments work by reducing blood flow to hemorrhoids, causing them to shrink, or by removing them entirely. The decision between non-operative management and early surgical excision should be based on local expertise and patient’s preference, as suggested by recent guidelines 1.
Surgical Intervention
Surgical excision of thrombosed external hemorrhoids under local anesthesia can be safely performed with a low recurrence and complication rate, as reported in a study by Jongen et al. 1. However, the use of incision and drainage of the thrombus is not recommended due to the higher incidence of bleeding and relapse of symptoms 1.
When to Seek Medical Attention
Seek medical attention if you experience severe pain, bleeding, or if symptoms don't improve after a week of home treatment. It is essential to prioritize the patient's preference and physician's expertise in deciding the best course of treatment, especially in cases of complicated hemorrhoids 1.
From the Research
Treatment Options for External Hemorrhoids
- Conservative treatment is considered the first-line approach for external hemorrhoidal thrombosis (EHT) and includes options such as:
- Wait and see
- Mixture of flavonoids
- Mix of lidocaine and nifedipine
- Botulinum toxin injection
- Topical application of 0.2% glyceryl trinitrate 2
- Surgical treatments are recommended when EHT fails to respond to conservative management or when symptoms onset falls within the last 48-72 hours, and include:
- Drainage with radial incision
- Conventional excision
- Excision under local anesthesia
- Stapled technique 2
- Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 3
Factors Influencing Treatment Choice
- Symptoms duration is a key factor in choosing between medical and surgical treatment for EHT 2
- Hemorrhoidal size, thrombosis, and location can determine the extent of pain or discomfort, and influence treatment decisions 3
- Patient preference, degree of discomfort, bleeding, comorbidities, and other factors should also be considered when determining the order in which treatments are pursued 3