What are the treatment options for hemorrhoids?

Hemorrhoid Treatment Options

Treatment of hemorrhoids should follow a stepwise approach starting with conservative measures, progressing to office-based procedures, and finally surgical interventions for advanced cases that don't respond to other treatments. 1

Diagnosis and Classification

Hemorrhoids are classified into four grades that guide treatment:

• Grade I: Internal hemorrhoids that bleed but don't prolapse
• Grade II: Hemorrhoids that prolapse during defecation but reduce spontaneously
• Grade III: Hemorrhoids that prolapse and require manual reduction
• Grade IV: Permanently prolapsed hemorrhoids that cannot be reduced

Treatment Algorithm

First-Line: Conservative Management

For all hemorrhoid grades, start with:

1. Dietary and lifestyle modifications:

   • Increase fiber intake (25-30g daily)
   • Increase water intake
   • Proper bathroom habits (avoid straining and prolonged sitting)
   • Sitz baths for symptomatic relief 1

2. Medical therapy:

   • Topical treatments: anesthetics (lidocaine), mild corticosteroids (1% hydrocortisone)
   • Important: Limit steroid use to 7 days maximum to avoid perianal/anal mucosal thinning 1
   • Oral flavonoids may provide additional symptom relief 2

Second-Line: Office-Based Procedures

For persistent Grade I-III hemorrhoids:

• Rubber band ligation: Treatment of choice for Grade I-III hemorrhoids

  • Bands should be applied to mucosa at anorectal junction, not directly to hemorrhoidal tissue
  • Higher success rate than other office procedures 1, 3

• Other office procedures (less effective than rubber band ligation):

  • Sclerotherapy
  • Infrared coagulation
  • Bipolar coagulation 1

Third-Line: Surgical Interventions

For Grade III-IV hemorrhoids or failed conservative/office treatments:

1. Excisional hemorrhoidectomy:

   • Gold standard for advanced hemorrhoids
   • Closed technique (Ferguson) preferred over open (Milligan-Morgan) due to less postoperative pain and better wound healing 2
   • Highest success rate but more painful with longer recovery 1, 3

2. Stapled hemorrhoidopexy (Longo procedure):

   • Particularly suitable for circular hemorrhoids
   • Less postoperative pain, shorter operation time and hospital stay
   • Faster recovery but higher recurrence rate than excisional hemorrhoidectomy 2

3. Hemorrhoidal Artery Ligation (HAL) with or without Recto-Anal Repair (RAR):

   • Better tolerated but higher recurrence rate
   • Option for Grade III hemorrhoids 2

Special Considerations

Thrombosed External Hemorrhoids

• Early excision under local anesthesia within 2-3 days of symptom onset significantly reduces pain 3
• Alternative: Topical nifedipine with lidocaine (92% resolution rate) 1

High-Risk Patients

• Pregnancy: Conservative management preferred
• Immunocompromised patients: Careful monitoring required
• Patients on antithrombotic agents: Requires special consideration before procedures 1

When to Refer for Surgical Evaluation

• Symptoms persisting beyond 8 weeks despite conservative treatment
• Grade III-IV hemorrhoids
• Recurrent symptoms after office-based procedures 1

Common Pitfalls to Avoid

1. Prolonged use of topical steroids (>7 days) can cause skin thinning and increased injury risk 1

2. Failure to rule out other conditions - atypical anal symptoms should prompt investigation for:

   • Inflammatory bowel disease (Crohn's, ulcerative colitis)
   • Cancer
   • HIV/AIDS
   • Other conditions 1

3. Unnecessary surgical intervention for low-grade hemorrhoids that could be managed conservatively 4

4. Outdated treatments to avoid: anal dilation, sphincterotomy, cryosurgery, galvanic electrotherapy, and heat therapy 2

Recent evidence suggests that consistent implementation of dietary fiber supplementation and proper defecation habits (TONE: Three minutes at defecation, Once-a-day frequency, No straining, Enough fiber) may help avoid surgery even in many patients with advanced hemorrhoids 4.