What is the treatment for external hemorrhoids?

Treatment of External Hemorrhoids

The cornerstone of treatment for external hemorrhoids is non-operative management with dietary and lifestyle changes, including increased fiber and water intake along with adequate bathroom habits. 1

Initial Management

Conservative Treatment

• Dietary modifications:

  • Increase fiber intake (aim for 25-30g daily)
  • Ensure adequate hydration
  • Avoid straining during defecation 1

• Topical treatments:

  • Topical muscle relaxants for thrombosed or strangulated hemorrhoids 1
  • Topical analgesics for pain and itching relief 1
  • Topical corticosteroids for perianal inflammation (limit use to 7 days to avoid skin thinning) 1

• Oral medications:

  • Flavonoids may be used to relieve symptoms 1
  • Stool softeners if constipation is present 2

Management of Thrombosed External Hemorrhoids

Early Presentation (within 72 hours)

• Surgical excision under local anesthesia is the most effective treatment for early thrombosed external hemorrhoids 1, 3, 4
• The procedure involves:
  • Elliptical incision over the thrombosis
  • Removal of the entire thrombosed hemorrhoidal plexus in one piece
  • Care must be taken to avoid cutting into the underlying sphincter muscle 4

Late Presentation (after 72 hours)

• Conservative management is appropriate as pain typically resolves after 7-10 days 1
• Avoid simple incision and drainage of the thrombus 1

Treatment Algorithm Based on Severity

1. Asymptomatic external hemorrhoids:

   • No treatment required

2. Mildly symptomatic external hemorrhoids:

   • Conservative treatment with dietary modifications
   • Topical treatments for symptom relief

3. Thrombosed external hemorrhoids:

   • If within 72 hours of onset: surgical excision under local anesthesia
   • If beyond 72 hours: conservative management

4. External hemorrhoids with significant skin tags:

   • Consider surgical removal if hygiene is difficult 5

Important Considerations and Pitfalls

• Rectal bleeding evaluation: All patients with rectal bleeding should undergo appropriate evaluation (sigmoidoscopy, colonoscopy) to rule out other causes, especially if bleeding is not typical of hemorrhoids 1

• Corticosteroid use: Prolonged use of potent corticosteroid preparations can cause skin thinning and should be avoided 1

• Post-excision care: After surgical excision of thrombosed hemorrhoids, prescribe stool softeners to prevent tearing at the suture line 4

• Recurrence prevention: Long-term dietary modifications with adequate fiber and water intake are essential to prevent recurrence 1

The 2021 World Society of Emergency Surgery guidelines strongly recommend non-operative management as first-line therapy for complicated hemorrhoids, with surgical excision reserved for specific cases of thrombosed hemorrhoids based on local expertise and patient preference 1.

When to Refer to a Specialist

• Persistent symptoms despite conservative management
• Recurrent thrombosed hemorrhoids
• Uncertainty about the diagnosis
• Significant bleeding requiring further evaluation
• Need for surgical intervention beyond office-based procedures

By following this treatment algorithm, most patients with external hemorrhoids can be effectively managed with good outcomes in terms of symptom relief and prevention of complications.