From the Guidelines
The most effective management option for hemorrhoids is a stepwise approach, starting with non-operative management as first-line therapy, including dietary and lifestyle changes, and considering surgical interventions only for severe or persistent cases, as recommended by the most recent guidelines 1.
Management Options
The management of hemorrhoids depends on the severity of symptoms and the grade of the hemorrhoids. For mild to moderate hemorrhoids, conservative measures are often sufficient. These include:
- Increasing dietary fiber (25-30g daily) and water intake to soften stool and reduce straining during bowel movements
- Avoiding prolonged sitting and straining during bowel movements
- Using over-the-counter topical preparations containing hydrocortisone (0.5-1%) for inflammation, pramoxine for pain, or witch hazel for soothing effects, applied up to four times daily for symptom relief
- Taking warm sitz baths for 10-15 minutes, 2-3 times daily to reduce discomfort
Office-Based Procedures
For more symptomatic hemorrhoids, office-based procedures may be considered, including:
- Rubber band ligation: placing small bands around hemorrhoid tissue to cut off circulation
- Sclerotherapy: injecting a solution to shrink hemorrhoids
- Infrared coagulation: using infrared radiation to coagulate and shrink hemorrhoids
Surgical Interventions
Persistent or severe hemorrhoids may require surgical interventions, such as:
- Hemorrhoidectomy: surgical removal of the hemorrhoid
- Stapled hemorrhoidopexy: a procedure that uses a stapler to lift and reposition the hemorrhoid tissue
Indications for Surgical Treatment
The decision to proceed with surgical treatment should be based on the severity of symptoms, the grade of the hemorrhoids, and the patient's preferences, as well as local expertise 1. Surgical treatment may be considered for patients with thrombosed hemorrhoids, but the decision should be made on a case-by-case basis, taking into account the patient's individual circumstances and the availability of expertise 1.
Key Considerations
The choice of treatment depends on various factors, including:
- Hemorrhoid grade
- Patient symptoms
- Comorbidities
- Patient preferences It is essential to address the underlying causes of hemorrhoids, which include increased pressure in the lower rectum due to straining, prolonged sitting, chronic constipation or diarrhea, and weakening of supporting tissues with age. By taking a stepwise approach and considering the individual patient's needs and circumstances, healthcare providers can provide effective management for hemorrhoids and improve patient outcomes.
From the Research
Management Options for Hemorrhoids
The management of hemorrhoids can be divided into non-operative and operative approaches.
- Non-operative approaches include:
- Lifestyle modification
- Fiber supplement
- Suppository-delivered anti-inflammatory drugs
- Administration of venotonic drugs
- Sclerotherapy
- Rubber band ligation 2
- Operative approaches include:
Treatment Selection
The choice of procedure should be based on the patient's symptoms, the extent of the hemorrhoidal disease, and the experience of the surgeon 3.
- Internal hemorrhoids that fail to respond to non-operative measures or complex internal and external hemorrhoidal disease may require a surgical hemorrhoidectomy 3.
- Stapled hemorrhoidopexy can be used to treat symptomatic internal hemorrhoids, but it should be employed with care and only after thorough training of the surgeon due to the risk of rare, severe complications 3.
- Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly 4.
Grading and Treatment
Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse 4.