How to treat a thrombosed hemorrhoid?

From the Guidelines

Thrombosed hemorrhoids should be treated with a decision between non-operative management and early surgical excision based on local expertise and patient’s preference. The treatment of thrombosed hemorrhoids involves a combination of home remedies and medical interventions. For immediate relief, apply an ice pack to the affected area for 10-15 minutes several times daily to reduce swelling and pain. Take over-the-counter pain relievers like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) according to package directions. Sitz baths—sitting in warm water for 15-20 minutes three times daily—can help soothe discomfort. Use unscented, alcohol-free wet wipes instead of toilet paper, and apply over-the-counter hemorrhoid creams containing hydrocortisone (such as Preparation H) to reduce inflammation.

Some key points to consider in the treatment of thrombosed hemorrhoids include:

• The use of incision and drainage of the thrombus is not recommended due to the higher incidence of bleeding and relapse of symptoms 1.
• Early surgical excision may result in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals 1.
• Flavonoids may be administered to relieve symptoms, although the evidence is based on moderate quality evidence 1.
• Topical muscle relaxants may be used in patients with thrombosed or strangulated hemorrhoids, although the evidence is based on low-quality evidence 1.

For severe pain or large clots, seeing a doctor within 72 hours of symptom onset is recommended, as they may perform an external thrombectomy—a minor procedure where the clot is removed through a small incision under local anesthesia 1. This provides immediate relief when done early. Thrombosed hemorrhoids occur when blood pools and clots in an external hemorrhoid, causing intense pain, swelling, and a bluish lump near the anus. While most resolve on their own within 1-2 weeks with conservative treatment, medical intervention can speed recovery and provide faster pain relief.

It's worth noting that the evidence for the treatment of thrombosed hemorrhoids is scarce and of low quality, making it difficult to provide evidence-based recommendations 1. However, based on the available evidence, a decision between non-operative management and early surgical excision should be made based on local expertise and patient’s preference 1.

From the Research

Treatment Options for Thrombosed Hemorrhoids

• Conservative treatment is often considered the first-line approach for thrombosed hemorrhoids, with options including:
  • Topical application of 0.2% glyceryl trinitrate 2
  • Mixture of flavonoids 2
  • Mix of lidocaine and nifedipine 2, 3
  • Botulinum toxin injection 2
• Surgical treatment may be recommended when conservative management fails or when symptoms onset falls within the last 48-72 hours, with options including:
  • Drainage with radial incision 2
  • Conventional excision 2, 4, 5
  • Excision under local anesthesia 2
  • Stapled technique 2, 6, 5
• Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 4, 5
• Rubber band ligation is a preferred office-based treatment for grades I to III internal hemorrhoids, with a lower failure rate than infrared photocoagulation 6, 5
• Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often used as initial therapy 5
• Dietary modifications, such as increased fiber and water intake, and behavioral therapies, such as sitz baths, may also be recommended 5

Specific Treatment Studies

• A study published in 2001 found that topical application of nifedipine ointment was effective in healing acute thrombosed external hemorrhoids, with complete relief of pain in 86% of patients after 7 days of therapy 3
• A review published in 2012 discussed the pathophysiology, epidemiology, risk factors, classification, clinical evaluation, and current non-operative and operative treatment of hemorrhoids, including the use of sclerotherapy and rubber band ligation 6
• A study published in 2018 discussed the diagnosis and treatment options for hemorrhoids, including medical management, dietary modifications, and surgical treatment, and recommended excision of thrombosed external hemorrhoids within the first two to three days of symptoms 5
• A mini-review published in 2022 evaluated conservative and surgical management of external hemorrhoidal thrombosis, and considered special conditions such as pregnancy and elderly patients 2