From the Guidelines
Current guidelines for external hemorrhoids recommend a stepwise approach to management, with initial treatment focusing on conservative measures including increasing dietary fiber intake and maintaining adequate hydration, as well as avoiding straining during bowel movements, as suggested by 1 and 1. The management of external hemorrhoids involves a combination of lifestyle modifications and medical interventions. Key aspects of conservative management include:
- Increasing dietary fiber intake to 25-30 grams daily
- Maintaining adequate hydration with 6-8 glasses of water daily
- Avoiding straining during bowel movements
- Using sitz baths (warm water soaks) for 10-15 minutes, 2-3 times daily to provide significant symptomatic relief
- Applying over-the-counter topical treatments containing ingredients like witch hazel, hydrocortisone (0.5-1%), or pramoxine 3-4 times daily for up to 7 days to reduce pain and inflammation
- Using oral pain relievers such as acetaminophen or ibuprofen as needed For persistent or severe cases, prescription-strength hydrocortisone (2.5%) or combination products containing lidocaine may be prescribed for short-term use (typically 1-2 weeks) 1. Thrombosed external hemorrhoids causing severe pain may benefit from surgical excision if performed within 72 hours of onset, with the decision between non-operative management and early surgical excision based on local expertise and patient’s preference, as suggested by 1 and 1. Prevention strategies include avoiding prolonged sitting, regular exercise, and prompt defecation when the urge occurs. These guidelines are based on the understanding that external hemorrhoids result from distended vascular tissue beneath the anal canal, and treatments aim to reduce swelling, alleviate discomfort, and prevent complications while promoting healing. The use of flavonoids, such as micronized, purified flavonoid fraction (MPFF), may also be beneficial in relieving symptoms, as suggested by 1 and 1. However, the role of other medical and pharmacological therapies, such as NSAIDs, topical steroids, and injection of local anesthetics, is not well established, and no recommendation can be made regarding their use in the treatment of complicated hemorrhoids, as stated by 1, 1, and 1.
From the Research
Current Guidelines for External Hemorrhoids
- The current guidelines for external hemorrhoids recommend excision of thrombosed external hemorrhoids to greatly reduce pain if performed within the first two to three days of symptoms 2.
- Medical management, dietary modifications, and behavioral therapies are the mainstays of initial therapy for hemorrhoids, including external hemorrhoids 2.
- For external hemorrhoids, treatment options such as surgical hemorrhoidectomy may be considered for severe cases, with postoperative wound care being critical for recovery 3.
Treatment Options
- Excisional hemorrhoidectomy is a surgical option for external hemorrhoids, which can lead to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures 2.
- Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids, as patients may experience less pain and recover more quickly 2, 4.
- Stapled hemorrhoidopexy is another option, which elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue, but has several potential postoperative complications 2, 4.
Postoperative Care
- Myrrh sitz baths have been shown to be effective in enhancing healing after hemorrhoidectomy, but cautious usage must be considered due to the higher complication rate 3.
- Standard wound care is also an option, but may not be as effective as Myrrh sitz baths in promoting wound healing after hemorrhoidectomy 3.