From the Guidelines
For patients with hemorrhoids, the most appropriate initial treatment is non-operative management with dietary and lifestyle changes, including increased fiber and water intake, as well as adequate bathroom habits, as recommended by the World Journal of Emergency Surgery in 2021 1. This approach is supported by strong evidence and is considered the first line of therapy.
- Key lifestyle changes include:
- Increasing fiber intake to 25-30g daily
- Drinking plenty of water, 8-10 glasses daily
- Avoiding straining during bowel movements
- Over-the-counter treatments that may provide relief include:
- Witch hazel pads
- Hydrocortisone creams (0.5-1%, applied up to 3-4 times daily for no more than 7 days)
- Oral pain relievers like acetaminophen or ibuprofen
- Warm sitz baths for 15-20 minutes several times daily can also provide significant relief. For patients with complicated hemorrhoids, flavonoids may be administered to relieve symptoms, as suggested by the American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids in 2004 1. Additionally, rubber band ligation, sclerotherapy, infrared coagulation, or surgical options like hemorrhoidectomy may be considered for persistent or more severe hemorrhoids, as discussed in the American Gastroenterological Association medical position statement in 2004 1. It's essential to note that surgery should be recommended only for a small minority of patients, and the decision between non-operative management and early surgical excision should be based on local expertise and patient preference, as stated in the WSES-AAST guidelines in 2021 1. Maintaining bowel regularity through proper diet and hydration is crucial for preventing recurrence after any treatment.
From the Research
Treatment Options for Hemorrhoids
The treatment of hemorrhoids can be divided into several categories, including:
- Conservative treatment: This approach is effective in managing the majority of patients complaining of early stages of the disease, and includes dietary and lifestyle modifications, as well as oral phlebotonic drugs and topical medications 2.
- Medical management: This includes the use of stool softeners, topical over-the-counter preparations, and topical nitroglycerine 3.
- Office-based treatment: Rubber band ligation is a preferred next step for grades I to III internal hemorrhoids, as it has a lower failure rate than infrared photocoagulation 3.
- Surgical treatment: This includes open or closed (conventional) excisional hemorrhoidectomy, which leads to greater surgical success rates but also incurs more pain and a prolonged recovery 3.
- Minimally invasive treatment options: These include mucopexy with or without mucosal resection, hemorrhoid artery ligation, and stapled hemorrhoidopexy, which aim to correct the underlying pathophysiological mechanisms involved in the aetiology of hemorrhoids 4, 3, 5.
Factors Influencing Treatment Choice
The choice of treatment depends on several factors, including:
- Hemorrhoidal size, thrombosis, and location 3
- Degree of discomfort, bleeding, and comorbidities 3
- Patient preference 3
- Severity of disease 2, 5
Recent Developments in Treatment
Recent studies have introduced new procedures or procedural refinements to existing techniques, with promising short-term outcomes 5. However, long-term follow-up or equivalency data are still being accumulated, and a definitive answer to what is truly the best alternative to traditional hemorrhoidectomy remains controversial 5.