What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The treatment of hemorrhoids should follow a stepwise approach, starting with dietary and lifestyle modifications as first-line therapy, progressing to office-based procedures for persistent symptoms, and reserving surgical intervention for advanced cases or when other treatments fail. 1

Classification and Assessment

Hemorrhoids are classified into four grades, which guide treatment decisions:

• First-degree: Internal hemorrhoids that bleed but do not prolapse
• Second-degree: Hemorrhoids that prolapse but reduce spontaneously
• Third-degree: Hemorrhoids that prolapse and require manual reduction
• Fourth-degree: Hemorrhoids that cannot be reduced and remain prolapsed 2, 1

First-Line Treatment: Conservative Management

Dietary and Lifestyle Modifications

• Increase fiber intake: Strong recommendation based on moderate quality evidence 1
  • Psyllium supplements (5-6 teaspoons daily with 600mL water) can reduce hemorrhoidal bleeding and painful defecation 2, 3
  • Target 25-30g of fiber daily
• Adequate water consumption: Prevents hard stools and straining 1
• Proper bathroom habits: Follow the "TONE" approach 3:
  • T: Three minutes maximum at defecation
  • O: Once-a-day defecation frequency
  • N: No straining during bowel movements
  • E: Enough fiber

Topical Treatments

• Topical analgesics: Provide symptomatic relief of pain and itching 2, 1
• Corticosteroid creams: May reduce local inflammation but do not reduce swelling, bleeding, or protrusion 2, 1
  • Caution: Long-term use of high-potency corticosteroids should be avoided due to harmful thinning of perianal tissue 1
• Topical muscle relaxants: Suggested specifically for thrombosed or strangulated hemorrhoids 1
• Topical nifedipine with lidocaine: Can achieve 92% resolution rate for thrombosed hemorrhoids 1

Oral Medications

• Flavonoids (including diosmin): Suggested to relieve hemorrhoid symptoms by increasing venous tone and lymphatic drainage 2, 1
  • Weak recommendation based on moderate quality evidence
  • May be used when first-line treatment is insufficient

Second-Line Treatment: Office-Based Procedures

For persistent symptoms despite conservative management:

Rubber Band Ligation

• First choice among non-operative techniques 1
• Success rate: 90% for grades 1-2 hemorrhoids and some grade 3 hemorrhoids 1
• Lowest recurrence rate among non-operative techniques 1

Sclerotherapy

• Option for first and second-degree hemorrhoids 1
• Quick procedure requiring no anesthesia
• Higher relapse rate compared to rubber band ligation 1

Other Non-Operative Techniques

• Infrared coagulation
• Bipolar coagulation

Third-Line Treatment: Surgical Intervention

Indicated for:

• Symptomatic third-degree hemorrhoids
• Fourth-degree hemorrhoids
• Mixed internal/external hemorrhoids
• Failed non-operative treatment
• Concomitant anorectal conditions requiring surgery 1

Surgical Options

• Hemorrhoidectomy: Most effective surgical option but more painful 1
• Stapled hemorrhoidopexy: Less painful but higher recurrence rate 1
• Minimally invasive operations:
  • Ligasure hemorrhoidectomy
  • Doppler-guided hemorrhoidal artery ligation 4

Special Considerations

Thrombosed Hemorrhoids

• Early diagnosis and excision under local anesthesia is the best management (92% resolution rate) 1
• Avoid incision and drainage of the thrombus due to risk of infection and delayed healing 1

Discontinued Treatments

• Cryotherapy: No longer recommended due to high complication rates, prolonged pain, and foul-smelling discharge 1
• Manual dilatation of the anus: Not recommended due to risk of sphincter injury and incontinence 1

Treatment Algorithm by Hemorrhoid Grade

1. First-degree hemorrhoids:

   • Medical therapy with fiber and water intake
   • Topical treatments for symptom relief

2. Second-degree hemorrhoids:

   • Medical therapy first
   • If persistent: Rubber band ligation or sclerotherapy

3. Third-degree hemorrhoids:

   • Small: Office-based procedures
   • Large: Surgical intervention

4. Fourth-degree hemorrhoids:

   • Surgical intervention 1

Key Pitfalls to Avoid

• Misdiagnosis: Anal pain suggests other pathology (e.g., anal fissures in 20% of patients with hemorrhoids) 2
• Overuse of corticosteroids: Can cause harmful thinning of perianal tissue 1
• Neglecting dietary modifications: Adequate fiber supplement combined with the TONE method can prevent surgery in most patients with advanced hemorrhoids 3
• Inappropriate treatment selection: Treatment must be matched to hemorrhoid grade for optimal outcomes 2, 1

Research shows that with proper conservative management including adequate fiber supplementation and lifestyle modifications, surgery can be avoided in many patients, even those with advanced hemorrhoids 3.