What is the treatment for a large symptomatic hemorrhoid?

From the Guidelines

Treatment for a large symptomatic hemorrhoid typically begins with conservative measures, but for severe cases, surgical hemorrhoidectomy may be necessary, as indicated by the most recent guidelines 1. When considering treatment options, it's essential to prioritize conservative measures first, including sitz baths, over-the-counter topical treatments, oral pain relievers, stool softeners, and increased fiber intake. These measures can help reduce inflammation, manage pain, and prevent constipation, which can worsen hemorrhoids.

• Conservative measures:
  • Sitz baths (warm water soaks) for 10-15 minutes, 2-3 times daily
  • Over-the-counter topical treatments containing hydrocortisone (0.5-1%) or witch hazel
  • Oral pain relievers such as acetaminophen or ibuprofen
  • Stool softeners like docusate sodium (100mg twice daily) and increased fiber intake (25-30g daily) with adequate hydration For persistent or severe cases, medical procedures may be necessary, including:
• Rubber band ligation
• Sclerotherapy
• Infrared coagulation
• Surgical hemorrhoidectomy for very large or prolapsed hemorrhoids These interventions work by either cutting off blood supply to the hemorrhoid, causing it to shrink, or by removing the hemorrhoid tissue entirely. According to the American Gastroenterological Association medical position statement 1, indications for elective hemorrhoidectomy include failure of medical and nonoperative therapy, symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids, and patient preference. Lifestyle modifications are also crucial, including avoiding prolonged sitting, straining during bowel movements, and maintaining regular physical activity to improve circulation and reduce pressure in the rectal veins. The decision between non-operative management and early surgical excision for thrombosed hemorrhoids should be based on local expertise and patient’s preference, as suggested by the WSES-AAST guidelines 1.

From the Research

Treatment Options for Large Symptomatic Hemorrhoids

• Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 2
• If medical therapy is inadequate, surgical intervention is warranted 2
• For grade 3 hemorrhoids, rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed 2
• Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids 2
• Office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step if medical management is unsuccessful 3
• Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids because patients may experience less pain and recover more quickly 3

Surgical Interventions

• Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate 2
• Excisional hemorrhoidectomy leads to greater surgical success rates but also incurs more pain and a prolonged recovery than office-based procedures 3
• Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain 3
• Stapled hemorrhoidopexy elevates grade III or IV hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue, but has several potential postoperative complications 3

Postoperative Care

• Postoperative pain from excisional hemorrhoidectomy can be treated with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics 2
• Sitz baths can be used as a behavioral therapy to help manage symptoms 3