From the Guidelines
The first-line treatment for external hemorrhoids should be conservative measures, but for thrombosed external hemorrhoids, excision under local anesthesia is recommended if diagnosed early, as it can provide more rapid symptom resolution and lower incidence of recurrence, as suggested by the most recent guidelines 1. When managing external hemorrhoids, it's essential to consider the following approaches:
- Conservative measures such as sitz baths (warm water soaks) for 10-15 minutes, 2-3 times daily
- Increased fiber intake (25-30g daily)
- Adequate hydration (8 glasses of water daily)
- Over-the-counter pain relievers like acetaminophen or ibuprofen as needed for discomfort
- Topical treatments containing hydrocortisone 1% or witch hazel to reduce inflammation and itching when applied 3-4 times daily for up to one week
- Stool softeners such as docusate sodium (100mg twice daily) to prevent straining These measures work by reducing swelling, improving blood flow to the area, softening stool to reduce trauma during bowel movements, and decreasing inflammation. However, for thrombosed external hemorrhoids, excision under local anesthesia is the preferred treatment if diagnosed early, as it can provide more rapid symptom resolution and lower incidence of recurrence 1. It's also important to avoid prolonged sitting, straining during bowel movements, and using rough toilet paper, which can worsen symptoms. If symptoms persist beyond two weeks, worsen significantly, or if there is severe pain or bleeding, medical evaluation is necessary as surgical intervention may be required, with the decision between non-operative management and early surgical excision based on local expertise and patient’s preference 1.
From the Research
First-Line Treatment for External Hemorrhoids
The first-line treatment for external hemorrhoids typically involves conservative management to alleviate symptoms.
- Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 2.
- For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, is the optimal management 3.
- Nonsurgical treatment includes increased fiber intake, sitz baths, and drugs 3.
- External hemorrhoid usually requires no specific treatment unless it becomes acutely thrombosed or causes patients discomfort 4.
Treatment Options
Treatment options for external hemorrhoids depend on the severity of symptoms and the presence of complications.
- Excision is the most effective treatment for thrombosed external hemorrhoids 5.
- Conservative management with lifestyle modification, fiber supplement, suppository-delivered anti-inflammatory drugs, and administration of venotonic drugs can be effective in most instances 6.
- Non-operative approaches include sclerotherapy and, preferably, rubber band ligation, although these are more commonly used for internal hemorrhoids 6.
Thrombosed External Hemorrhoids
Thrombosed external hemorrhoids can be treated conservatively or excised.