What is the initial treatment for hemorrhoids?

Initial Treatment for Hemorrhoids

The initial treatment for hemorrhoids should focus on conservative management with a high-fiber diet (25-30g daily), increased water intake (8-10 glasses daily), and lifestyle modifications to alleviate symptoms before considering procedural interventions. 1

Diagnosis and Classification

Proper diagnosis is essential before initiating treatment:

• Classification of hemorrhoids:

  • First-degree: Bleed but do not prolapse
  • Second-degree: Prolapse but reduce spontaneously
  • Third-degree: Prolapse requiring manual reduction
  • Fourth-degree: Permanently prolapsed 2, 1

• Diagnostic approach:

  • External examination to identify external hemorrhoids, skin tags, or other pathology
  • Anoscopy is essential for proper visualization of internal hemorrhoids
  • Rule out other causes of symptoms (anal fissures, abscesses, rectal varices) 2, 1

Important: Hemorrhoids alone do not cause positive stool guaiac tests. Fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated. 2

Conservative Management (First-Line Treatment)

1. Dietary modifications:

   • High-fiber diet (25-30g daily)
   • Increased water intake (8-10 glasses daily) 1, 3
   • Bulk-forming fiber supplements (5-6 teaspoons of psyllium husk with 600mL water daily) 3

2. Lifestyle modifications (TONE approach):

   • T: Three minutes maximum at defecation
   • O: Once-a-day defecation frequency
   • N: No straining during bowel movements
   • E: Enough fiber 3
   • Avoid prolonged sitting on the toilet 1
   • Regular physical activity 1

3. Topical treatments:

   • Phlebotonics (flavonoids) for symptom relief 1
   • Low-potency topical corticosteroids (hydrocortisone 1%) limited to 7 days maximum 1
   • Topical lidocaine for acute pain relief, especially with thrombosed external hemorrhoids 1
   • Sitz baths for symptomatic relief 4

Treatment Algorithm Based on Hemorrhoid Grade

1. First-degree hemorrhoids:

   • Conservative management with dietary and lifestyle modifications
   • Topical treatments for symptomatic relief 1, 4

2. Second-degree hemorrhoids:

   • Start with conservative management
   • If failed, proceed to office-based procedures:
     • Rubber band ligation (preferred, 80% improvement rate) 1
     • Sclerotherapy (alternative, 89.9% improvement but higher recurrence) 1

3. Third-degree hemorrhoids:

   • Office procedures or surgical intervention depending on severity 1
   • Consider rubber band ligation for smaller hemorrhoids 4

4. Fourth-degree hemorrhoids:

   • Surgical intervention (hemorrhoidectomy) 1

Special Considerations

• Thrombosed external hemorrhoids:

  • Excision within first 2-3 days of symptoms can greatly reduce pain 4
  • Topical lidocaine for symptomatic relief 1

• Pregnancy:

  • Conservative management is preferred
  • Careful monitoring due to increased infection risk 1

• Patients on antithrombotic agents:

  • May need medication adjustment before surgical procedures 1

• Immunocompromised patients:

  • Require careful monitoring due to increased infection risk 1

Effectiveness of Conservative Approach

Research shows that adequate fiber supplementation combined with the TONE approach can prevent progression of hemorrhoids and reduce bleeding episodes, potentially avoiding surgery in 87.1% of patients with advanced hemorrhoids 3. This demonstrates the importance of starting with conservative management before considering more invasive procedures.

Caution: Pain is generally not associated with uncomplicated hemorrhoids. Anal pain suggests other pathology (such as thrombosis, fissure, or abscess) and warrants closer investigation. 2