What is the best treatment for hemorrhoids?

Best Treatment for Hemorrhoids

The best treatment for hemorrhoids is increased dietary fiber and water intake as first-line therapy, with topical treatments for symptom relief and appropriate procedural interventions based on hemorrhoid grade. 1

Treatment Algorithm Based on Hemorrhoid Classification

First-Degree Hemorrhoids (bleeding without prolapse)

1. Medical management (first-line):

   • Increased dietary fiber (25-30g/day) and water intake 1
   • Stool softeners if needed
   • Avoid straining during defecation
   • Topical analgesics for pain/itching relief

2. If medical management fails:

   • Sclerotherapy (injection of 5% phenol in oil, 5% quinine and urea, or hypertonic salt solution) 1
   • Rubber band ligation has lowest recurrence rate among non-operative techniques 1

Second-Degree Hemorrhoids (prolapse with spontaneous reduction)

1. Medical management (first-line) as above
2. If medical management fails:
   • Rubber band ligation (preferred due to lower recurrence rate) 1, 2
   • Alternative office procedures: infrared coagulation, bipolar coagulation

Third-Degree Hemorrhoids (prolapse requiring manual reduction)

1. Medical management for smaller third-degree hemorrhoids
2. Procedural options:
   • Rubber band ligation for smaller third-degree hemorrhoids 1, 2
   • Surgical hemorrhoidectomy for larger third-degree hemorrhoids that extend to dentate line 1
   • Stapled hemorrhoidopexy as alternative (faster recovery but higher recurrence) 3

Fourth-Degree Hemorrhoids (prolapse that cannot be reduced)

1. Surgical intervention required:
   • Excisional hemorrhoidectomy (most effective treatment) 1, 2, 3
   • Stapled hemorrhoidopexy (alternative with faster recovery but higher recurrence) 3

Thrombosed External Hemorrhoids

• Early presentation (within 72 hours): Excision under local anesthesia 1, 3
• Late presentation (>72 hours) or resolving symptoms: Conservative management with:
  • Pain control
  • Sitz baths
  • Topical muscle relaxants 1
  • Avoid incision and drainage (not recommended) 1

Pharmacological Management

First-Line Medications

• Fiber supplements: Psyllium or methylcellulose (shown to reduce bleeding and painful defecation) 1
• Topical analgesics: For symptomatic relief of pain and itching 1
• Flavonoids: Recommended to relieve symptoms (moderate evidence) 1

Second-Line Medications

• Topical muscle relaxants: For thrombosed or strangulated hemorrhoids 1
• Topical corticosteroids: Short-term use (<7 days) for perianal inflammation 1
  • Caution: Long-term use of high-potency corticosteroid creams is harmful and should be avoided 1

Special Populations

Pregnant Women

• Conservative management is preferred
• Topical hydrocortisone cream may provide symptomatic relief 4
• Mechanical support devices may be beneficial 4

Important Caveats and Pitfalls

• Misdiagnosis: Hemorrhoidal symptoms can mimic other conditions. All patients reporting rectal bleeding should undergo sigmoidoscopy 1
• Colorectal cancer screening: Proximal colon evaluation (colonoscopy/barium enema) is necessary for:
  • Bleeding not typical of hemorrhoids
  • Guaiac-positive stools
  • Anemia
  • Risk factors for colorectal cancer 1
• Immunocompromised patients: Higher risk for severe infection after rubber band ligation 1
• Prolonged steroid use: Avoid using topical corticosteroids for more than 7 days due to risk of skin thinning 1
• Cryotherapy: High complication rate and no longer recommended 1

By following this treatment algorithm based on hemorrhoid classification and symptom severity, most patients can achieve significant symptom relief and improved quality of life.