From the Guidelines
External hemorrhoids are best managed with a combination of home remedies, over-the-counter medications, and potentially surgical excision under local anesthesia, depending on the severity of symptoms and patient preference, as suggested by the most recent guidelines 1. When diagnosed early, thrombosed external hemorrhoids can be effectively treated with excision under local anesthesia in the office or clinic, as recommended by the American Gastroenterological Association 1. However, if symptoms are resolving, excision may not be required, as the pain associated with hemorrhoidal thrombosis typically resolves after 7–10 days.
Home Remedies and Over-the-Counter Medications
Treatment for external hemorrhoids typically involves:
- Warm sitz baths for 15-20 minutes, 2-3 times daily to reduce swelling and discomfort
- Over-the-counter creams containing hydrocortisone (0.5-1%) or witch hazel pads to reduce inflammation and itching
- Oral pain relievers like acetaminophen (Tylenol) or ibuprofen (Advil, Motrin) to manage pain
- Increasing fiber intake to 25-30 grams daily through foods or supplements like psyllium husk (Metamucil)
- Drinking 6-8 glasses of water daily to soften stool
- Avoiding straining during bowel movements and limiting sitting on the toilet for extended periods
Surgical Excision
If symptoms persist beyond one week or are severe (significant pain, bleeding, or thrombosis), consulting a healthcare provider is necessary, as prescription medications or minor procedures like surgical excision under local anesthesia may be needed, as suggested by the World Journal of Emergency Surgery guidelines 1. The decision between non-operative management and early surgical excision should be based on local expertise and patient’s preference, with a weak recommendation against the use of incision and drainage of the thrombus due to higher incidence of bleeding and relapse of symptoms 1.
From the Research
Treatment Options for External Hemorrhoids
- Nonsurgical treatment for nonthrombosed hemorrhoids includes increased fiber intake, sitz baths, and drugs 2
- For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, is the optimal management 2, 3
- Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 4
- Thrombosed external hemorrhoids can be treated conservatively or excised 4, 5, 6
Surgical Intervention
- Excision is the most effective treatment for thrombosed external hemorrhoids 5
- Hemorrhoidectomy is performed through an elliptic incision over the site of thrombosis with removal of the entire diseased hemorrhoidal plexus in one piece 3
- Stool softeners must be prescribed postoperatively to help prevent tearing at the suture line 3