What is the treatment for acute thrombosed hemorrhoids?

From the Guidelines

The treatment for acute thrombosed hemorrhoids typically involves a combination of conservative measures and, in some cases, surgical intervention, with the decision between non-operative management and early surgical excision based on local expertise and patient’s preference, as suggested by the 2021 WSES-AAST guidelines 1.

Initial Management

Initial management includes:

• Pain control with oral analgesics such as acetaminophen or NSAIDs (ibuprofen 400-600mg every 6-8 hours or naproxen 500mg twice daily)
• Warm sitz baths for 10-15 minutes 2-3 times daily
• Topical anesthetics containing lidocaine
• Stool softeners like docusate sodium (100mg twice daily) to prevent constipation

Surgical Intervention

For severe cases presenting within 72 hours of symptom onset, surgical excision under local anesthesia is often the most effective approach for immediate pain relief. This procedure involves making an elliptical incision over the thrombosed hemorrhoid, removing the clot, and excising the redundant tissue. Conservative management is generally preferred for patients presenting after 72 hours, as the acute pain typically begins to resolve naturally after this period.

Conservative Management

Conservative management is generally preferred for patients presenting after 72 hours, as the acute pain typically begins to resolve naturally after this period. Thrombosed hemorrhoids result from blood clot formation within an external hemorrhoid, causing sudden, severe pain and a bluish-purple lump at the anal opening. Most cases will resolve spontaneously within 1-2 weeks with conservative measures, but surgical intervention provides faster pain relief when performed early in the course of symptoms.

Pharmacological Regimen

In patients with complicated hemorrhoids, non-operative management as first line therapy, with dietary and lifestyle changes (i.e., increased fiber and water intake together with adequate bathroom habits) is recommended 1. Additionally, flavonoids may be administered to relieve symptoms 1, and topical muscle relaxant may be used in patients with thrombosed or strangulated hemorrhoids 1.

Role of Endoscopy

In patients with complicated hemorrhoids, anoscopy as part of the physical examination is suggested, whenever feasible and well tolerated 1. Additionally, colonoscopy may be performed in case of concern for inflammatory bowel disease or cancer arising from patient personal and family history, or from physical examination 1.

Medical Treatment

Medical treatment includes adding dietary fiber and avoiding straining at stool. Psyllium may be used to reduce hemorrhoidal bleeding and painful defecation 1. Topical analgesics and corticosteroid creams may also be used to bring symptomatic relief of local pain and itching. Long-term use of high-potency corticosteroid creams should be avoided 1.

Evaluation and Classification

A precise patient history and a careful physical examination are essential for accurate diagnosis. Bleeding is the most common presenting symptom of hemorrhoids, and further investigation is warranted to rule out other causes of bleeding 1. Anoscopy and flexible sigmoidoscopy are recommended for bright-red rectal bleeding, and complete colonic evaluation by colonoscopy or air-contrast barium enema is indicated when the bleeding is atypical for hemorrhoids.

From the Research

Treatment Options for Acute Thrombosed Hemorrhoids

• The treatment for acute thrombosed hemorrhoids can be either conservative or surgical, depending on the severity of the condition and the patient's overall health 2, 3, 4, 5, 6.
• Conservative treatment typically involves stool softeners, analgesics, rest, warm soaks, and ice packs to relieve symptoms and reduce discomfort 2, 3, 4.
• Surgical treatment, such as excision and evacuation of the clot, is usually recommended for patients who do not respond to conservative treatment or have severe symptoms 2, 3, 5, 6.
• Excision of the thrombosed external hemorrhoid can provide rapid symptom resolution, lower incidence of recurrence, and longer remission intervals compared to conservative treatment 6.

Factors Influencing Treatment Choice

• The decision to choose conservative or surgical treatment depends on various factors, including the patient's medical history, the severity of symptoms, and the presence of other health conditions 2, 3, 4, 5, 6.
• Patients with a prior history of thrombosed external hemorrhoids may be more likely to undergo surgical treatment 6.
• The presence of pain, bleeding, or a lump may also influence the choice of treatment, with surgical treatment being more commonly recommended for patients with these symptoms 6.

Outcomes and Recurrence Rates

• The recurrence rate for thrombosed external hemorrhoids is higher in patients who undergo conservative treatment compared to those who undergo surgical treatment 6.
• The time to recurrence is also shorter in patients who undergo conservative treatment, with a mean time to recurrence of 7.1 months compared to 25 months in patients who undergo surgical treatment 6.
• Overall, surgical treatment appears to be more effective in preventing recurrence and reducing symptoms in patients with acute thrombosed hemorrhoids 6.