What is the initial treatment for chronic thrombosed external hemorrhoids?

From the Guidelines

The initial treatment for chronic thrombosed external hemorrhoids is conservative management, focusing on symptom relief and prevention of further complications, as most cases will resolve spontaneously within 1-2 weeks. This approach is supported by the most recent and highest quality study available, which suggests the use of flavonoids to relieve symptoms in patients with complicated hemorrhoids, including those with thrombosed external hemorrhoids 1. Conservative management includes:

• Warm sitz baths for 10-15 minutes several times daily to reduce pain and discomfort
• Topical analgesics containing lidocaine or pramoxine for pain relief
• Oral non-steroidal anti-inflammatory drugs (NSAIDs) like ibuprofen (400-600 mg three times daily) for pain relief
• Stool softeners such as docusate sodium (100 mg twice daily) to prevent constipation
• Increased dietary fiber intake to 25-30 grams daily
• Adequate hydration with 6-8 glasses of water per day

It is essential to note that surgical excision may be considered if symptoms are severe or persist beyond 2-3 days despite conservative management, as suggested by a previous study 1. However, the most recent guideline recommends the use of topical muscle relaxant, like topical nitrates and calcium channels antagonists, for the treatment of thrombosed hemorrhoids, which may provide additional relief for patients with severe anal pain 1.

Key considerations in the management of chronic thrombosed external hemorrhoids include:

• Avoiding the use of steroid cream for more than 7 days to prevent potential thinning of perianal and anal mucosa and increasing risk of injury 1
• Not recommending the use of NSAIDs, topical steroids, or injection of local anesthetics due to lack of evidence supporting their effectiveness in treating complicated hemorrhoids 1
• Considering the use of phlebotonics, such as flavonoids, which have shown beneficial effects in reducing symptoms of hemorrhoids, including pruritus, bleeding, and discharge 1

From the Research

Initial Treatment for Chronic Thrombosed External Hemorrhoids

• The initial treatment for chronic thrombosed external hemorrhoids typically involves conservative management, including medical and behavioral therapies 2.
• Conservative treatment options may include stool softeners, topical over-the-counter preparations, and sitz baths 2.
• Topical nifedipine has been shown to be effective in reducing pain and promoting healing in acute thrombosed external hemorrhoids 3.
• A combination of topical nifedipine and lidocaine may be more effective than lidocaine alone in reducing pain and promoting healing 3, 4.

Surgical Treatment

• Surgical treatment, such as excision of the thrombosed external hemorrhoid, may be considered if conservative management is unsuccessful or if the patient presents within the first 72 hours of symptom onset 2, 5.
• Excision of the thrombosed external hemorrhoid can provide significant relief from pain and reduce the risk of further complications 5, 4.
• The choice of surgical treatment may depend on the individual patient's circumstances, including the severity of symptoms and the presence of any underlying medical conditions 6.

Comparison of Treatment Options

• The optimal treatment for chronic thrombosed external hemorrhoids is still a matter of debate, with both conservative and surgical options having been proposed 6, 4.
• A review of the literature suggests that surgical treatment may be superior to conservative treatment in terms of symptom relief, but more research is needed to determine the optimal treatment approach 4.
• The use of topical nifedipine and other conservative treatment options may be a useful alternative to surgical treatment for some patients 3, 6.