From the Guidelines
Treatment for external hemorrhoids should prioritize non-operative management as first-line therapy, with dietary and lifestyle changes, and consider surgical excision based on local expertise and patient preference for thrombosed hemorrhoids. This approach is supported by the most recent guidelines from the World Journal of Emergency Surgery 1. The treatment plan should include increasing fiber intake to 25-30 grams daily, drinking plenty of water (6-8 glasses per day), and avoiding straining during bowel movements. For immediate relief, applying cold compresses to the affected area for 15 minutes several times daily and warm sitz baths for 15-20 minutes, 2-3 times daily can reduce swelling and pain.
Over-the-counter treatments such as topical creams containing hydrocortisone (0.5-1%) can be applied sparingly to the external area up to 3-4 times daily for no more than 7 consecutive days to reduce inflammation. Pain relievers like acetaminophen (up to 3000mg daily in divided doses) or ibuprofen (up to 1200mg daily) can help manage discomfort. Witch hazel pads or medicated wipes can provide cooling relief after bowel movements.
For severe cases, especially thrombosed hemorrhoids, surgical excision under local anesthesia is suggested based on patient preference and local expertise 1. This approach is supported by studies showing that surgical excision can lead to more rapid symptom resolution and lower recurrence rates compared to non-operative management 1. However, the decision between non-operative management and surgical excision should be made on a case-by-case basis, considering the patient's overall health, symptoms, and preferences.
It's essential to note that incision and drainage of the thrombus are not recommended due to higher incidence of bleeding and relapse of symptoms 1. If symptoms persist beyond one week, worsen, or include significant bleeding, a medical evaluation is necessary to determine the best course of treatment.
From the Research
Treatment Options for External Hemorrhoids
- External hemorrhoids can be treated with various methods, including medical and surgical approaches 2, 3, 4, 5, 6
- For thrombosed external hemorrhoids, excision is considered an effective treatment option, especially if performed within the first two to three days of symptoms 2, 3, 6
- Conservative treatment, 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 be considered as the first-line approach for external hemorrhoidal thrombosis 6
- Surgical treatments, including drainage with radial incision, conventional excision, excision under local anesthesia, and stapled technique, are recommended when conservative management fails or when symptoms onset falls within the last 48-72 hours 6
Factors Influencing Treatment Choice
- The choice of treatment for external hemorrhoids depends on various factors, including the severity of symptoms, patient preference, and the presence of any complications 2, 4, 5
- The duration of symptoms is also an important factor in determining the treatment approach, with surgical treatment often recommended for symptoms that have lasted for more than 48-72 hours 6
Special Considerations
- Special conditions, such as pregnancy and external hemorrhoidal thrombosis in elderly patients, require careful consideration and management 6
- The management and treatment of external hemorrhoidal thrombosis is still controversial, and randomized clinical trials and structured consensus-based guidelines are warranted to provide clear guidance on the best treatment approaches 6