From the Guidelines
The initial treatment for hemorrhoids should focus on non-operative management as first-line therapy, with dietary and lifestyle changes, such as increased fiber and water intake, as well as adequate bathroom habits, as recommended by the most recent guidelines 1. This approach is based on moderate quality evidence and is aimed at relieving symptoms and preventing worsening of the condition.
- Key components of conservative management include:
- Increasing dietary fiber intake to 25-30 grams daily
- Drinking plenty of water (6-8 glasses) to soften stools and reduce straining
- Using over-the-counter pain relievers like acetaminophen or ibuprofen to manage discomfort
- Applying topical treatments such as witch hazel pads, hydrocortisone creams (0.5-1%, applied up to 3-4 times daily for no more than 1-2 weeks), or over-the-counter hemorrhoid creams containing phenylephrine to reduce swelling and pain
- Taking sitz baths (sitting in warm water for 10-15 minutes, 2-3 times daily) to provide significant relief
- Avoiding prolonged sitting, especially on the toilet, and using moist wipes instead of dry toilet paper These conservative measures work by reducing inflammation, improving blood flow to the area, and decreasing pressure on the hemorrhoidal vessels. Most hemorrhoid symptoms improve within 1-2 weeks with these conservative measures, as supported by the guidelines 1. If symptoms persist beyond 7-10 days, worsen, or include significant bleeding, medical evaluation is necessary as more advanced treatments may be required, as suggested by the available literature 1.
From the Research
Initial Treatment for Hemorrhoids
The initial treatment for hemorrhoids typically involves non-surgical methods, including:
- Dietary changes, such as increased fiber and water intake 2
- Stool softeners 3, 2
- Local hydrocortisone creams 3
- Sitz baths 2
- Topical over-the-counter preparations, such as topical nitroglycerine 2
Office-Based Treatments
If initial medical management is unsuccessful, office-based treatments may be considered, including:
- Rubber band ligation, which is a preferred next step for grades I to III internal hemorrhoids due to its lower failure rate compared to infrared photocoagulation 2
- Infrared coagulation, which may be used for internal hemorrhoids that fail bowel management programs 4
Surgical Options
Surgical options, such as hemorrhoidectomy, may be reserved for recurrent or higher-grade disease, including:
- Open or closed (conventional) excisional hemorrhoidectomy, which leads to greater surgical success rates but also incurs more pain and a prolonged recovery 2
- Stapled hemorrhoidopexy, which elevates grade III or IV hemorrhoids to their normal anatomic position but has several potential postoperative complications 2, 4
- Hemorrhoidal artery ligation, which may be useful in grade II or III hemorrhoids with less pain and quicker recovery 2
- Excision of thrombosed external hemorrhoids, which can greatly reduce pain if performed within the first two to three days of symptoms 2