From the Guidelines
Thrombosed hemorrhoids are best managed by surgical excision within the first 72 hours of symptoms, as it provides the most effective pain relief, according to the most recent and highest quality study 1.
Treatment Options
The decision between non-operative management and early surgical excision should be based on local expertise and patient’s preference, as suggested by the World Journal of Emergency Surgery study 1.
- Pain management with over-the-counter medications like acetaminophen or ibuprofen (400-600mg every 6-8 hours)
- Warm sitz baths for 15-20 minutes several times daily
- Topical treatments containing hydrocortisone or witch hazel to reduce swelling and discomfort
Conservative Measures
Conservative measures include:
- Increasing fiber intake (25-30g daily)
- Drinking plenty of water (8-10 glasses daily)
- Avoiding straining during bowel movements
- Using stool softeners like docusate sodium (100mg twice daily) if needed Most thrombosed hemorrhoids resolve within 1-2 weeks with conservative treatment, though the clot may leave a skin tag, as stated in the American Gastroenterological Association medical position statement 1.
Surgical Excision
Surgical excision under local anesthesia can be safely performed with a low recurrence and complication rate, as shown in a retrospective analysis of 340 patients 1. The procedure involves removing the clot under local anesthesia, providing rapid symptom resolution and lower incidence of recurrence. Incision and drainage of the thrombus is not recommended due to higher incidence of bleeding and relapse of symptoms 1.
From the Research
Thrombosed Hemorrhoid Treatment Options
- Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the first line of treatment for thrombosed hemorrhoids 2
- Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also help alleviate symptoms 2
- For external hemorrhoidal thrombosis, excision of the thrombosed hemorrhoid can greatly reduce pain if performed within the first two to three days of symptoms 2
- Conservative treatment options, such as wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection, and topical application of 0.2% glyceryl trinitrate, can also be effective 3
Surgical Treatment Options
- Surgical treatments, such as drainage with radial incision, conventional excision, excision under local anesthesia, and stapled technique, may be recommended when conservative management fails or when symptoms onset falls within the last 48-72 hours 3
- Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain 2
- Stapled hemorrhoidopexy can elevate grade III or IV hemorrhoids to their normal anatomic position, but has potential postoperative complications 2
Micronized Purified Flavonoid Fraction (MPFF) Treatment
- MPFF has been shown to be beneficial in treating bleeding, pain, pruritus, anal discharge/leakage, and overall improvement in patients with hemorrhoidal disease 4
- MPFF can improve patient-assessed treatment effect and reduce the rate of thrombosis and edema of mucocutaneous bridges after hemorrhoidectomy 5
- MPFF may also prevent postoperative perianal skin tags formation 5
Evidence Quality and Limitations
- The evidence for thrombosed hemorrhoid treatment is largely based on observational studies and expert opinion, with few randomized controlled trials available 6
- The optimal treatment approach remains unclear, and more research is needed to determine the best course of treatment for individual patients 3, 6