What is the workup and treatment for hemorrhoids?

Workup and Treatment for Hemorrhoids

The first-line management for hemorrhoids should be non-operative treatment with dietary and lifestyle modifications, including increased fiber and water intake along with proper bathroom habits. 1, 2

Diagnostic Workup

Initial Assessment

• Thorough medical history and physical examination are essential to differentiate hemorrhoids from other anorectal conditions
• Anoscopy should be performed as part of the physical examination when feasible and well tolerated 1
• Digital rectal examination to assess for masses, tenderness, and sphincter tone

Further Diagnostic Testing

• Colonoscopy is indicated when:
  • Patient has risk factors for colorectal cancer
  • Family history of colorectal cancer or inflammatory bowel disease
  • Concerning findings on physical examination
  • Age-appropriate screening is due 1, 2
• Imaging studies (such as endoanal ultrasound) should be considered only when there is suspicion of:
  • Anorectal abscess
  • Inflammatory bowel disease
  • Neoplasm
  • Other underlying conditions 1

Hemorrhoid Classification

• Grade I: Bleeding without prolapse
• Grade II: Prolapse with spontaneous reduction
• Grade III: Prolapse requiring manual reduction
• Grade IV: Irreducible prolapse 2, 3

Treatment Algorithm

1. Conservative Management (First-Line for All Grades)

• Dietary modifications:
  • Increase fiber intake to 25-30g daily
  • Add psyllium supplements
  • Ensure adequate water intake 2
• Lifestyle changes:
  • Proper bathroom habits (avoid straining)
  • Regular exercise
  • Avoid prolonged sitting 2
• Topical treatments:
  • Hydrocortisone cream for symptomatic relief (limited to 7 days to avoid tissue thinning) 2
  • Topical analgesics for pain relief
• Oral medications:
  • Flavonoids (including diosmin) to relieve symptoms by increasing venous tone 1, 2

2. Office-Based Procedures (For Grade I-III)

• Rubber band ligation: Preferred office-based procedure with 90% success rate and lowest recurrence rate among non-operative techniques 2, 3
• Sclerotherapy: Option for grade I-II hemorrhoids, but higher relapse rate than rubber band ligation 2
• Infrared coagulation: Alternative with 67-96% success rate for bleeding relief 2

3. Surgical Interventions (For Grade III-IV or Failed Conservative Treatment)

• Hemorrhoidectomy: Most effective surgical option but more painful 2, 3
  • Ferguson (closed) technique: Superior to Milligan-Morgan (open) technique regarding postoperative pain and wound healing 4
• Stapled hemorrhoidopexy (Longo procedure): Less painful with faster recovery but higher recurrence rate 2, 4
• Hemorrhoidal artery ligation (HAL): Better tolerated but higher recurrence rate 2, 4

4. Management of Complicated Hemorrhoids

Thrombosed External Hemorrhoids

• Early excision under local anesthesia is the best management with 92% resolution rate 2
• Topical nifedipine with lidocaine can achieve 92% resolution rate 2
• Avoid incision and drainage due to risk of infection and delayed healing 2

Hemorrhoids in Special Populations

• Pregnancy: Conservative management is preferred; surgical interventions only if absolutely necessary
• Immunocompromised patients: Careful monitoring for infections
• Patients on antithrombotic agents: Assess bleeding risk before procedures 5

Common Pitfalls and Caveats

1. Don't attribute all rectal bleeding to hemorrhoids without ruling out other serious conditions like colorectal cancer or inflammatory bowel disease 1, 2

2. Avoid prolonged use of topical corticosteroids (>7 days) as they can cause harmful thinning of perianal tissue 2

3. Outdated treatments to avoid:

   • Cryotherapy (high complication rates, prolonged pain)
   • Manual dilatation of the anus (risk of sphincter injury)
   • Anal dilation, sphincterotomy, and galvanic electrotherapy (obsolete with poor outcomes) 2, 4

4. Grade-specific treatment is essential for optimal outcomes - don't jump to surgical options for low-grade hemorrhoids that can be managed conservatively 2, 3