From the Guidelines
In Canada, the recommended treatment for painful external hemorrhoids, particularly thrombosed external hemorrhoids, is a combination of conservative measures and, in some cases, surgical intervention, with the most recent and highest quality evidence suggesting that surgical excision under local anesthesia within 72 hours of onset is often the most effective approach for immediate pain relief 1.
Key Recommendations
- For immediate relief, conservative management includes:
- Sitz baths (warm water soaks) for 10-15 minutes several times daily
- Application of over-the-counter topical treatments containing hydrocortisone (0.5-1%) or witch hazel to reduce inflammation and pain
- Oral pain relievers such as acetaminophen (up to 4000mg daily in divided doses) or ibuprofen (400-600mg three times daily with food)
- Stool softeners like docusate sodium (100mg twice daily) are advised to prevent constipation and reduce straining
- Patients should increase dietary fiber (25-30g daily) and fluid intake (at least 8 glasses of water daily) to soften stools and reduce pressure during bowel movements
Surgical Intervention
- For thrombosed external hemorrhoids specifically, if treated within 72 hours of onset, surgical excision under local anesthesia is often the most effective approach for immediate pain relief, as suggested by the most recent guidelines 1
- This procedure involves removing the clot and the affected hemorrhoidal tissue
- After 72 hours, conservative management is typically recommended as the benefits of surgery diminish
Monitoring and Follow-up
- If symptoms persist beyond 7-10 days despite conservative treatment, or if there is significant bleeding, severe pain, or fever, medical attention should be sought promptly as these may indicate complications requiring specialized treatment 1
- The decision between non-operative management and early surgical excision should be based on physician’s expertise and patient’s preference, as suggested by the recent guidelines 1
From the Research
Types of Hemorrhoids and Pain
- External hemorrhoids can cause acute pain if thrombosed 2, 3, 4
- Thrombosed external hemorrhoids are a common complication of hemorrhoidal disease and can cause extreme pain 3
- Internal hemorrhoids typically present with prolapse or painless rectal bleeding, whereas external hemorrhoids can also bleed and cause pain if thrombosed 2
Recommended Treatment in Canada for Painful External Hemorrhoids
- Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 2
- Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 4
- 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 3
- Surgical treatments, such as drainage with radial incision, conventional excision, excision under local anesthesia, and stapled technique, are recommended when external hemorrhoidal thrombosis fails to respond to conservative management or when symptoms onset falls within the last 48-72 hours 3
Treatment Options for Thrombosed External Hemorrhoids
- Urgent surgical treatment, performed within 72 hours of presentation, can prevent the negative economic and psychological effects of a prolonged recovery and limit the necessity for surgical intervention at a later date 5
- Excisional hemorrhoidectomy or stapled hemorrhoidopexy can be performed in patients with grade 3 hemorrhoids, but excisional hemorrhoidectomy may cause more postoperative pain and have a lower recurrence rate compared to stapled hemorrhoidopexy 2