From the Guidelines
Treatment for hemorrhoids should begin with non-operative management as the first-line therapy, including dietary and lifestyle changes, such as increased fiber and water intake, and adequate bathroom habits. This approach is supported by a strong recommendation based on moderate quality evidence [ 1 ].
Conservative Measures
Conservative measures can help alleviate symptoms and prevent recurrence. These include:
- Increasing fiber intake to 25-30 grams daily
- Drinking plenty of water
- Using over-the-counter remedies such as witch hazel pads, hydrocortisone cream (0.5-1%, applied sparingly up to 3-4 times daily for no more than 1-2 weeks), or over-the-counter hemorrhoid creams containing phenylephrine
- Warm sitz baths for 10-15 minutes, 2-3 times daily, to reduce inflammation and discomfort
- Oral pain relievers like acetaminophen or ibuprofen to manage pain
Medical Procedures
For persistent or severe hemorrhoids, medical procedures may be necessary, including:
- Rubber band ligation
- Sclerotherapy
- Infrared coagulation
- Surgical hemorrhoidectomy for the most severe cases
Pharmacological Regimen
In patients with complicated hemorrhoids, flavonoids may be administered to relieve symptoms, as suggested by a weak recommendation based on moderate quality evidence [ 1 ]. Additionally, topical muscle relaxants may be used in patients with thrombosed or strangulated hemorrhoids, although this is based on a weak recommendation with low-quality evidence [ 1 ].
Preventing Recurrence
Preventing recurrence involves maintaining soft stools through proper diet, regular exercise, avoiding straining during bowel movements, and not sitting on the toilet for extended periods.
It is essential to note that the role of NSAIDs, topical steroids, other topical agents, or injection of local anesthetics for complicated hemorrhoids is not well-established, and no recommendation can be made based on the available literature [ 1 ].
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 2
- Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also be effective in managing hemorrhoids 2, 3
- Office-based treatments, including rubber band ligation, are preferred for grades I to III internal hemorrhoids due to their lower failure rate compared to infrared photocoagulation 2
- Surgical options, such as open or closed excisional hemorrhoidectomy, are typically reserved for recurrent or higher-grade disease, as they can result in greater pain and a prolonged recovery 2, 3
Surgical Approaches
- Excisional hemorrhoidectomy is considered the gold-standard approach for grade IV hemorrhoids, but it can be associated with postoperative pain and complications 3, 4
- Minimally invasive treatments, including mucopexy with or without mucosal resection and hemorrhoid artery ligation, have been proposed for the management of grade III hemorrhoids, aiming to reduce postoperative pain and complications 3, 4
- Stapled hemorrhoidopexy is another surgical option, which elevates grade III or IV hemorrhoids to their normal anatomic position, but it can have potential postoperative complications 2, 3
Non-Operative Approaches
- Sclerotherapy and rubber band ligation are non-operative approaches that can be effective in treating hemorrhoids, especially for low-graded internal hemorrhoids 5, 3
- Lifestyle modification, fiber supplement, and administration of venotonic drugs are also non-operative methods that can be used to manage hemorrhoids 5