From the Guidelines
The emergency department management of a thrombosed external hemorrhoid should prioritize pain control and consider surgical excision under local anesthesia within 48-72 hours of symptom onset, as this approach may lead to more rapid symptom resolution and lower recurrence rates, as suggested by the most recent guidelines 1.
Initial Assessment and Management
The initial treatment of thrombosed external hemorrhoids involves pain control measures, including:
- Oral analgesics such as acetaminophen or NSAIDs
- Topical anesthetics like lidocaine 2% ointment
- Sitz baths 2-3 times daily for 10-15 minutes with warm water These measures aim to alleviate the patient's discomfort and facilitate the healing process.
Surgical Intervention
Surgical excision under local anesthesia (1% lidocaine with epinephrine) is recommended for patients presenting within 48-72 hours of symptom onset with significant pain and a well-defined clot, as it may provide more rapid symptom resolution and lower recurrence rates 1. The procedure involves making an elliptical incision over the thrombosis, evacuating the clot, and leaving the wound open to heal by secondary intention.
Post-Procedure Care
Post-procedure care includes:
- Continued sitz baths
- Stool softeners (docusate sodium 100mg twice daily)
- Increased fiber intake
- Adequate hydration
- Pain management These measures aim to promote wound healing, prevent complications, and alleviate the patient's discomfort.
Conservative Management
Conservative management is appropriate for patients presenting after 72 hours, those with diffuse thrombosis, or when surgical expertise is unavailable. Patients should be advised that symptoms typically resolve within 7-14 days with conservative treatment. Discharge instructions should include warning signs requiring return (severe bleeding, fever, increasing pain) and recommendations for preventing recurrence through dietary modifications and avoiding prolonged sitting or straining during defecation, as suggested by the guidelines 1.
From the Research
Emergency Department Management of Thrombosed External Hemorrhoid
The management of thrombosed external hemorrhoids in the emergency department involves both conservative and surgical options.
- Conservative treatment is often considered the first-line approach, with options including:
- Wait and see
- Mixture of flavonoids
- Mix of lidocaine and nifedipine
- Botulinum toxin injection
- Topical application of 0.2% glyceryl trinitrate 2
- Surgical treatment is recommended when conservative management fails or when symptoms onset falls within the last 48-72 hours, with options including:
- Drainage with radial incision
- Conventional excision
- Excision under local anesthesia
- Stapled technique 2
- Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 3, 4
- The choice of treatment remains controversial, and no specific guidelines have been published 2
Special Considerations
- Pregnancy and elderly patients require special consideration in the management of thrombosed external hemorrhoids 2
- The history and physical examination must assess for risk factors and clinical signs indicating more concerning disease processes 4