What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

Non-operative management with dietary and lifestyle changes should be the first-line therapy for hemorrhoids, including increased fiber and water intake along with adequate bathroom habits. 1

Classification of Hemorrhoids

Hemorrhoids are classified according to their symptoms and location:

• Internal hemorrhoids:

  • First-degree: Bleed but do not protrude
  • Second-degree: Protrude with defecation but reduce spontaneously
  • Third-degree: Protrude and require manual reduction
  • Fourth-degree: Cannot be reduced

• External hemorrhoids: Usually asymptomatic unless thrombosis occurs, causing acute pain 1

Treatment Algorithm

1. First-Line Treatment (All Grades)

• Dietary modifications:

  • Increased fiber intake (25-30g daily)
  • Adequate water intake
  • Regular bowel habits 1

• Topical treatments:

  • Flavonoids to relieve symptoms 1
  • Topical muscle relaxants for thrombosed/strangulated hemorrhoids 1
  • Topical corticosteroids for perianal skin irritation (limited to 7 days to avoid skin thinning) 1
  • Topical analgesics for pain management 1

2. Second-Line Treatment (Persistent Symptoms)

For Grade I-II Hemorrhoids:

• Office-based procedures:
  • Rubber band ligation (preferred due to lowest recurrence rate) 1, 2
  • Injection sclerotherapy (higher relapse rate) 1
  • Infrared coagulation 1
  • Bipolar coagulation 1

For Grade III Hemorrhoids:

• Office-based procedures (as above) or:
• Surgical options:
  • Doppler-guided hemorrhoidal artery ligation (less pain, faster recovery) 3, 4
  • Stapled hemorrhoidopexy (less pain than conventional surgery) 1, 4

For Grade IV Hemorrhoids:

• Surgical options:
  • Conventional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson) 1, 3
  • Stapled hemorrhoidopexy for circular hemorrhoids 4

3. Management of Thrombosed External Hemorrhoids

• Early presentation (within 2-3 days):

  • Surgical excision under local anesthesia (provides immediate pain relief) 1, 2

• Late presentation (>3 days) or resolving symptoms:

  • Conservative management as symptoms typically resolve in 7-10 days 1
  • Topical muscle relaxants 1
  • Avoid simple incision and drainage (higher recurrence and bleeding rates) 1

Special Considerations

• Immunocompromised patients: Higher risk for severe infection after rubber band ligation 1

• Prolonged symptoms: Evaluate for other anorectal conditions or colorectal pathology

• Rectal bleeding: All patients with rectal bleeding should undergo sigmoidoscopy to rule out other causes 1

Common Pitfalls to Avoid

1. Prolonged use of topical steroids: Limit to 7 days to prevent perianal skin thinning 1

2. Incision and drainage of thrombosed hemorrhoids: Associated with persistent bleeding and higher recurrence rates 1

3. Overlooking other causes of rectal bleeding: Always consider colonoscopy for atypical bleeding patterns, guaiac-positive stools, or anemia 1

4. Cryotherapy: No longer recommended due to high complication rates 1

5. Manual anal dilatation: Not recommended due to risk of sphincter injury and incontinence 1

The treatment approach should progress from conservative measures to more invasive options based on hemorrhoid grade and symptom persistence. While surgical options provide the highest success rates, they should be reserved for higher-grade disease or when conservative and office-based treatments fail due to increased pain and recovery time 1, 2.