From the Guidelines
External hemorrhoids are swollen blood vessels that develop under the skin around the anus, typically appearing as lumps or bulges around the anal opening and causing symptoms such as pain, itching, burning, and sometimes bleeding, especially during bowel movements. They differ from internal hemorrhoids in that they form outside the anal canal and are covered by sensitive skin, making them more likely to cause discomfort 1. The development of external hemorrhoids is often linked to increased pressure in the lower rectum from straining during bowel movements, chronic constipation, prolonged sitting, pregnancy, or obesity.
Some key factors to consider in the management of external hemorrhoids include:
- Maintaining regular bowel habits to reduce straining
- Avoiding prolonged sitting and taking regular breaks to move around
- Staying hydrated and eating a high-fiber diet to soften stools
- Exercising regularly to improve overall health and reduce pressure on the rectum
- Using over-the-counter pain relievers (such as acetaminophen or ibuprofen) and topical treatments containing hydrocortisone or witch hazel to manage symptoms
According to the american gastroenterological association technical review on the diagnosis and treatment of hemorrhoids 1, adding dietary fiber and avoiding straining at stool are almost-universal recommendations for managing hemorrhoids. Additionally, the use of psyllium has been shown to reduce hemorrhoidal bleeding and painful defecation in one double-blind, placebo-controlled trial 1. The use of topical analgesics and corticosteroid creams may bring symptomatic relief of local pain and itching, but long-term use of high-potency corticosteroid creams should be avoided due to potential deleterious effects.
In terms of specific treatments, nitroglycerin ointment has been shown to relieve pain due to thrombosed external hemorrhoids by decreasing anal tone 1. Oral micronized, purified flavonoid fraction (MPFF) has also been assessed as a potential treatment, with some studies showing symptomatic improvement, although results are inconsistent when combined with fiber 1. Overall, the management of external hemorrhoids should prioritize reducing symptoms and preventing further complications, with a focus on lifestyle modifications and medical treatments as needed.
From the Research
Definition and Characteristics of External Hemorrhoids
- External hemorrhoids are a type of hemorrhoid that can cause bleeding and acute pain if thrombosed 2, 3, 4, 5, 6
- They are characterized by engorged fibrovascular cushions lining the anal canal 3
- External hemorrhoids typically present with bleeding and can cause discomfort or pain, especially if thrombosed 2, 3, 4, 5
Symptoms and Diagnosis of External Hemorrhoids
- Symptoms of external hemorrhoids include bright red, painless rectal bleeding during defecation, although they can also cause acute pain if thrombosed 2, 3
- Diagnosis is typically made through physical examination and medical history 3, 5, 6
- Even if hemorrhoids are seen on examination, patients with rectal bleeding who are at risk of colorectal cancer should still undergo colonoscopy to exclude cancer as the etiology 3
Treatment Options for External Hemorrhoids
- Nonsurgical treatment for nonthrombosed external hemorrhoids includes increased fiber intake, sitz baths, and drugs 3
- For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, is the optimal management 3, 4
- Conservative treatment, such as wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection, and topical application of 0.2% glyceryl trinitrate, can be used as a first-line approach for external hemorrhoidal thrombosis 4
- Surgical treatments, such as drainage with radial incision, conventional excision, excision under local anesthesia, and stapled technique, are recommended when external hemorrhoidal thrombosis fails to respond to conservative management or when symptoms onset falls within the last 48-72 hours 4