What is better for thrombosed hemorrhoids, vasodilation or vasoconstriction?

Topical Muscle Relaxants Are Recommended for Thrombosed Hemorrhoids

For thrombosed hemorrhoids, topical muscle relaxants (vasodilation) are suggested as the appropriate pharmacological treatment rather than vasoconstrictors. 1

Management of Thrombosed Hemorrhoids

First-Line Approach

• Non-operative management is the recommended first-line therapy for complicated hemorrhoids, including thrombosed hemorrhoids 1:
  • Dietary and lifestyle changes (increased fiber and water intake with improved bathroom habits)
  • Topical muscle relaxants for thrombosed hemorrhoids specifically 1
  • Flavonoids to relieve symptoms 1

Mechanism and Rationale

Vasodilation through topical muscle relaxants helps reduce pain and discomfort by:

• Decreasing anal sphincter spasm
• Improving blood flow to the thrombosed area
• Potentially facilitating resolution of the thrombus

Surgical Considerations

• The decision between continued non-operative management and surgical excision should be based on:
  • Local expertise
  • Patient preference
  • Response to conservative therapy 1
• Complete surgical excision (not simple incision and drainage) is the most effective treatment for thrombosed external hemorrhoids that fail to respond to conservative measures 2, 3
• Guidelines specifically recommend against incision and drainage of the thrombus 1

Important Clinical Considerations

Pathophysiology Insights

• Thrombosed hemorrhoids often develop following constipation 3
• The stagnation of blood and trauma to anal vessels due to strain appears to be the common denominator in thrombosis development 3
• The condition is typically self-limiting and resolves within days to a week with proper management 3

Treatment Algorithm

1. Begin with topical muscle relaxants and lifestyle modifications
2. Add flavonoids for symptom relief
3. Consider surgical excision (not incision and drainage) if:
   • Severe pain persists
   • No improvement after conservative therapy
   • Patient preference after discussing options

Common Pitfalls to Avoid

• Using vasoconstrictors, which may worsen stasis and potentially exacerbate the condition
• Performing simple incision and drainage (explicitly recommended against in guidelines) 1
• Delaying surgical excision when indicated, as early excision provides better symptom relief for severe cases 2
• Failing to address underlying constipation, which is a key factor in development and recurrence 3

The guidelines do not make specific recommendations regarding NSAIDs, topical steroids, other topical agents, or injection of local anesthetics for complicated hemorrhoids due to insufficient evidence 1.