What is the best treatment for persistent hemorrhoids?

Treatment for Persistent Hemorrhoids

For persistent hemorrhoids, non-operative management with dietary and lifestyle changes (increased fiber and water intake with improved bathroom habits) is the recommended first-line therapy, followed by flavonoids for symptom relief, and rubber band ligation for cases that don't respond to conservative measures. 1

Initial Conservative Management

First-Line Approach

• Dietary and lifestyle modifications:
  • Increase fiber intake (bulk-forming agents like psyllium)
  • Ensure adequate water consumption
  • Establish proper bathroom habits (avoid straining)
  • Avoid prolonged sitting on toilet 1

Pharmacological Management

• Flavonoids (micronized purified flavonoid fraction) to relieve symptoms 1
  • Increases venous tone and lymphatic drainage
  • Normalizes capillary permeability
  • Note: Not FDA-approved in the United States 1
• Topical treatments:
  • Muscle relaxants for thrombosed/strangulated hemorrhoids 1
  • Analgesics for pain and itching relief 1
  • Short-term use of corticosteroid creams for inflammation (avoid long-term use) 1
  • Nitroglycerin ointment may help with thrombosed external hemorrhoids 1

Treatment Based on Hemorrhoid Classification

First-degree (bleeding without prolapse):

• Conservative management as described above
• If persistent: Consider sclerotherapy or infrared photocoagulation 1

Second-degree (prolapse that reduces spontaneously):

• Conservative management
• If persistent: Rubber band ligation (preferred office-based procedure) 1, 2
• Alternative: Sclerotherapy, infrared photocoagulation 1

Third-degree (prolapse requiring manual reduction):

• Initial trial of conservative management
• Rubber band ligation for smaller third-degree hemorrhoids 1
• Surgical hemorrhoidectomy for larger third-degree hemorrhoids that extend to dentate line 1

Fourth-degree (irreducible prolapse):

• Surgical hemorrhoidectomy 1
• Stapled hemorrhoidopexy as an alternative with less post-operative pain 3

Office-Based Procedures for Persistent Cases

Rubber Band Ligation

• Most effective non-operative procedure with lowest recurrence rate 1, 2
• Best for first-, second-, and smaller third-degree hemorrhoids
• Technique: Tight encirclement of redundant tissue at least 2cm proximal to dentate line
• Caution: May cause more discomfort than other office procedures 1
• Contraindication: Immunocompromised patients (increased risk of infection) 1

Sclerotherapy

• Reserved for first- and second-degree hemorrhoids 1
• Higher relapse rate compared to rubber band ligation 1
• Technique: Submucosal injection of sclerosing agent at hemorrhoid base

Infrared Photocoagulation

• Alternative for first- and second-degree hemorrhoids
• Less effective than rubber band ligation but causes less pain 1

Surgical Options for Refractory Cases

Conventional Hemorrhoidectomy

• Most effective treatment overall, especially for third- and fourth-degree hemorrhoids 1, 2
• Indications:
  • Failure of medical and non-operative therapy
  • Symptomatic third- or fourth-degree hemorrhoids
  • Concurrent anorectal condition requiring surgery 1
• Techniques:
  • Open (Milligan-Morgan) or closed (Ferguson) approaches
  • Closed technique may have advantages for post-operative pain and healing 3

Stapled Hemorrhoidopexy

• Less post-operative pain than conventional hemorrhoidectomy
• Faster recovery and shorter hospital stay
• Higher recurrence rate 3
• Particularly suitable for circular hemorrhoids 3

Important Clinical Considerations

• Avoid cryotherapy - high complication rate and no longer recommended 1
• Avoid manual anal dilatation - risk of sphincter injury and incontinence 1
• For thrombosed external hemorrhoids:
  • Early excision (within 2-3 days of symptoms) under local anesthesia 4
  • Conservative management if symptoms are resolving (pain typically resolves in 7-10 days) 1
• Evaluate for other causes of rectal bleeding in patients with risk factors for colorectal cancer 1
• Rubber band ligation should be performed at least 2cm proximal to dentate line to avoid severe pain 1

By following this stepwise approach based on hemorrhoid severity and response to treatment, most patients with persistent hemorrhoids can achieve significant symptom relief and improved quality of life.