What is the best treatment for hemorrhoids (piles)?

From the Guidelines

The best treatment for hemorrhoids is non-operative management as the first-line therapy, with dietary and lifestyle changes, including increased fiber and water intake, as well as adequate bathroom habits, as recommended by the most recent guidelines 1.

Key Recommendations

• Increase fiber intake to 25-30 grams per day to soften stools and reduce straining
• Drink plenty of water to promote healing and reduce symptoms
• Take warm sitz baths for 10-15 minutes, 2-3 times daily, to soothe the area and promote healing
• Apply over-the-counter hemorrhoid creams or suppositories containing hydrocortisone to reduce inflammation and itching
• Use witch hazel pads for cleaning and soothing the area after bowel movements
• For pain relief, take over-the-counter pain medications like acetaminophen or ibuprofen as needed
• Avoid prolonged sitting and use a donut-shaped cushion to reduce pressure on the affected area

Rationale

The recommendation for non-operative management as the first-line therapy is based on moderate quality evidence, with a strong recommendation (1B) from the World Journal of Emergency Surgery 1. This approach prioritizes dietary and lifestyle changes, which have been shown to be effective in reducing symptoms and promoting healing. The use of flavonoids, such as micronized, purified flavonoid fraction (MPFF), may also be beneficial in relieving symptoms, although the evidence is moderate and the recommendation is weak (2B) 1.

Additional Considerations

• Office-based procedures, such as rubber band ligation, sclerotherapy, and infrared coagulation, may be considered for patients with complicated hemorrhoids, but the evidence is limited and no recommendation can be made based on the available literature 1.
• Topical muscle relaxants may be used to relieve pain in patients with thrombosed or strangulated hemorrhoids, although the evidence is low-quality and the recommendation is weak (2C) 1.
• Lifestyle changes, such as maintaining a healthy weight and avoiding straining during bowel movements, can help prevent recurrence of hemorrhoids.

From the Research

Treatment Options for Hemorrhoids

• Conservative treatment based on dietary and lifestyle changes can help the majority of patients 2
• Rubber band ligation and phlebotonic drugs can effectively treat grade I and II haemorrhoids 2
• Surgery is required for the most advanced stages, with Milligan-Morgan haemorrhoidectomy considered the gold-standard approach for grade IV haemorrhoids 2
• Minimally invasive treatment options, including mucopexy with or without mucosal resection and haemorrhoid artery ligation, are available for grade III haemorrhoids 2
• Adequate dietary fiber supplement and TONE (specifying exact treatment goals: three minutes at defecation, once-a-day defecation frequency, no straining during passing motions, and enough fiber) can help avoid surgery in most patients with advanced hemorrhoids 3

Special Considerations

• Patients with inflammatory bowel diseases, pregnancy, immunosuppression, coagulopathy, cirrhosis with portal hypertension, and proctitis after radiotherapy require special consideration and caution when treating hemorrhoids 4
• Conservative medical approach associated with the treatment of the primary disease is recommended as the first-line treatment for these patients 4
• Surgical treatment of hemorrhoids in patients with certain conditions, such as Crohn's disease or previous pelvic radiotherapy, can be unsafe and should be approached with caution 4

Pregnancy and Puerperium

• Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium includes dietary modifications, stimulants or depressants of the bowel transit, local treatment, and phlebotonics 5
• Rutosides seem to be effective in reducing the signs and symptoms of haemorrhoidal disease, but their use cannot be recommended until new evidence reassures women and their clinicians about their safety 5

Guidelines and Recommendations

• The Association of Colon & Rectal Surgeons of India (ACRSI) practice guidelines for the management of haemorrhoids-2016 provide recommendations for diagnosis and management, including dietary, non-surgical, and surgical techniques 6