From the Guidelines
The optimal treatment for hemorrhoids involves non-operative management as first-line therapy, with dietary and lifestyle changes, such as increased fiber and water intake, and adequate bathroom habits, as recommended by the most recent guidelines 1. This approach is supported by strong evidence, with a strong recommendation based on moderate quality evidence (1B) from the World Journal of Emergency Surgery 1. The key components of this treatment include:
- Increasing fiber intake to 25-30 grams daily through diet or supplements
- Staying hydrated by drinking 6-8 glasses of water daily
- Avoiding straining during bowel movements
- Implementing adequate bathroom habits Additional treatments, such as flavonoids to relieve symptoms, may be considered, although the evidence is weaker (2B) 1. For severe cases, such as symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids, or when non-operative management fails, surgical options like hemorrhoidectomy may be considered, as recommended by the American Gastroenterological Association 1. However, surgery should be reserved for a small minority of patients due to the associated pain and complications.
From the Research
Optimal Treatment for Hemorrhoids
The optimal treatment for hemorrhoids depends on the severity of the disease and the patient's expectations.
- Conservative treatment is effective in managing the majority of patients complaining of early stages of the disease 2.
- Dietary and lifestyle modifications, such as increasing dietary fiber, are the first therapeutic step necessary to achieve regular defecation with soft stool 2, 3.
- Oral phlebotonic drugs can help to control symptoms, and the use of topical medications can be beneficial during the acute phase or in the post-operative period 2, 4.
- The "TONE" method, which entails specifying exact treatment goals (three minutes at defecation, once-a-day defecation frequency, no straining during passing motions, and enough fiber), can help avoid surgery in most patients with advanced hemorrhoids 3.
Special Considerations
- In special conditions, such as pregnancy, inflammatory bowel diseases, immunosuppression, coagulopathy, cirrhosis with portal hypertension, and proctitis after radiotherapy, the management of hemorrhoids is challenging and requires caution 5.
- Patients in pregnancy can be effectively treated with medical therapy, reserving surgical intervention in highly selected and urgent cases 5.
- In case of thrombosed hemorrhoids, excision allows for fast symptom resolution, with a low incidence of recurrence and a long remission interval 5.
- In case of immunosuppressed patients, there is no consensus for the best treatment, but surgical procedures can be safely proposed when indicated 5.
Surgical Treatment
- Surgery should be the last resort, and the patient should be well-informed of the surgical alternatives, including the possibility of elective ambulatory surgery, if appropriate 6.
- Postoperative pain should be prevented by the systematic implementation of a pudendal block and multimodal use of analgesics 6.
- In case of previous pelvic radiotherapy, conservative treatment is advocated due to the risk of severe complications, such as abscesses and fistulas with subsequent pelvic and retroperitoneal sepsis 5.