What are the management options for painful hemorrhoids?

Management of Painful Hemorrhoids

For painful hemorrhoids, non-operative management is recommended as first-line therapy, with dietary and lifestyle changes including increased fiber and water intake together with adequate bathroom habits. 1

Initial Assessment

When evaluating painful hemorrhoids:

• Perform a focused history and digital rectal examination to rule out other causes of anorectal pain 1
• Perform anoscopy when feasible and well tolerated to confirm the diagnosis 1
• Consider colonoscopy only if there are concerns for inflammatory bowel disease or cancer based on patient history or physical examination 1
• Imaging (CT, MRI, endoanal ultrasound) is only indicated if there's suspicion of concomitant anorectal diseases like abscess, IBD, or neoplasm 1

Classification of Hemorrhoids

Hemorrhoids are classified based on symptoms and anatomy:

• First-degree: Bleed but do not protrude
• Second-degree: Protrude with defecation but reduce spontaneously
• Third-degree: Protrude and require digital reduction
• Fourth-degree: Cannot be reduced 1

Treatment Algorithm

1. First-Line Treatment (All Painful Hemorrhoids)

• Dietary and lifestyle modifications:

  • Increased fiber intake (5-6 teaspoons of psyllium husk with 600 mL water daily) 2
  • Increased water intake
  • Proper bathroom habits (TONE method: Three minutes at defecation, Once-a-day frequency, No straining, Enough fiber) 2

• Pharmacological management:

  • Flavonoids to relieve symptoms 1
  • Topical muscle relaxants for thrombosed or strangulated hemorrhoids 1
  • Topical analgesics for pain relief 1
  • Avoid prolonged use of high-potency corticosteroid creams 1

2. For Thrombosed External Hemorrhoids

• If presenting early (within 2-3 days of onset):

  • Excision under local anesthesia is best for rapid pain relief 1, 3
  • Avoid simple incision and drainage of the thrombus 1

• If symptoms are already resolving:

  • Continue conservative management as pain typically resolves after 7-10 days 1

3. For Internal Hemorrhoids by Grade

• First-degree hemorrhoids:

  • Continue medical therapy with fiber and water 1
  • If medical therapy fails, consider office-based procedures

• Second and third-degree hemorrhoids:

  • If non-operative management fails, consider office-based procedures:
    • Rubber band ligation (preferred due to lowest recurrence rate) 1, 3
    • Injection sclerotherapy (for first and second-degree only)
    • Infrared coagulation
  • Note: These procedures don't require anesthesia and can be performed in outpatient settings

• Third and fourth-degree hemorrhoids:

  • Surgical hemorrhoidectomy if non-operative approaches fail 1
  • Options include conventional excisional hemorrhoidectomy, Ligasure hemorrhoidectomy, or stapled hemorrhoidopexy 4

Special Considerations

• Acutely painful, prolapsed, incarcerated hemorrhoids:

  • Either hemorrhoidectomy or excision of external component with rubber band ligation of internal hemorrhoids 1

• Immunocompromised patients:

  • Higher risk for infection after procedures, particularly rubber band ligation 1
  • Exercise caution with office-based procedures

Common Pitfalls to Avoid

1. Misdiagnosis: Not all anorectal pain is due to hemorrhoids; rule out fissures, abscesses, or fistulas 1

2. Inappropriate treatment selection: Matching treatment to hemorrhoid grade is essential for success

3. Overlooking serious pathology: Never blindly attribute rectal bleeding to hemorrhoids without appropriate evaluation 1

4. Overuse of corticosteroid creams: Long-term use of high-potency corticosteroid preparations can be harmful 1

5. Inadequate fiber supplementation: Many treatment failures occur due to insufficient fiber intake or poor compliance with lifestyle modifications 2

The evidence strongly supports that most patients with painful hemorrhoids, even advanced ones, can avoid surgery with proper implementation of dietary fiber supplementation and correction of deranged defecation habits 2. Surgery should be reserved for cases that fail conservative management or have specific indications for immediate surgical intervention.