What are the treatment guidelines for hemorrhoids?

Treatment Guidelines for Hemorrhoids

For hemorrhoid management, treatment should be based on the hemorrhoid grade, with conservative measures for first and second-degree hemorrhoids, office procedures for persistent second and third-degree hemorrhoids, and surgical intervention for fourth-degree hemorrhoids. 1

Diagnosis and Classification

Proper diagnosis is essential before initiating treatment:

• Classification system:

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

• Diagnostic approach:

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

Important: Anal pain is generally not associated with uncomplicated hemorrhoids and suggests other pathology such as thrombosis, fissure, or abscess, warranting closer investigation. 1

Treatment Algorithm Based on Hemorrhoid Grade

First-Degree Hemorrhoids

1. Conservative management:
   • High-fiber diet (25-30g daily)
   • Increased water intake (8-10 glasses daily)
   • Lifestyle modifications (regular physical activity, avoiding prolonged sitting on toilet)
   • Phlebotonics (flavonoids) for symptom relief 1

Second-Degree Hemorrhoids

1. Start with conservative management as above
2. If conservative treatment fails, proceed to office procedures:
   • Rubber band ligation (preferred): 80% improvement and 69% symptom-free at 5-year follow-up 1
   • Sclerotherapy (alternative): 89.9% improvement or cure but higher recurrence rate (30% at 4 years) 1

Third-Degree Hemorrhoids

1. Office procedures (rubber band ligation)
2. Surgical intervention if office procedures fail:
   • Conventional hemorrhoidectomy (Ferguson closed technique preferred over Milligan-Morgan open technique)
   • Stapled hemorrhoidopexy (particularly for circular hemorrhoids)
   • Hemorrhoidal artery ligation (HAL/RAR) 1, 2

Fourth-Degree Hemorrhoids

1. Surgical intervention:
   • Conventional hemorrhoidectomy
   • Stapled hemorrhoidopexy
   • HAL/RAR in selected cases 1, 2

Conservative Management Details

• Dietary modifications:

  • High-fiber diet (25-30g daily)
  • Adequate hydration (8-10 glasses of water daily) 1

• Topical treatments (limited to 7 days):

  • Low-potency topical corticosteroids (hydrocortisone 1%)
  • Avoid prolonged use to prevent skin and mucosal atrophy 1

• Oral medications:

  • Phlebotonics (flavonoids): Effective for itching, bleeding, secretion, and overall symptom improvement 1

Office-Based Procedures

Rubber Band Ligation

• Procedure of choice for persistent first and second-degree hemorrhoids 1
• Technique: Places rubber bands around the base of hemorrhoids, causing tissue necrosis and fixation
• Follow-up: Evaluate for symptom improvement 1-2 weeks after procedure
• Side effects: Pain (5-60% of patients), usually mild and manageable with sitz baths and OTC analgesics
• Complications: Rare but serious complications include necrotizing pelvic sepsis, especially in immunocompromised patients 1

Sclerotherapy

• Alternative to rubber band ligation
• Efficacy: 89.9% improvement or cure in first/second-degree hemorrhoids
• Limitation: Higher recurrence rate (30% at 4 years) 1

Surgical Management

Conventional Hemorrhoidectomy

• Gold standard for advanced hemorrhoids
• Technique: Excision of hemorrhoidal tissue
• Variants:
  • Ferguson (closed) technique: Superior for postoperative pain and wound healing
  • Milligan-Morgan (open) technique 2

Stapled Hemorrhoidopexy (Longo Procedure)

• Benefits: Reduced postoperative pain, shorter operation time and hospital stay, faster recovery
• Drawback: Higher recurrence rate
• Best for: Circular hemorrhoids and can be used for acute anal prolapse 2

Hemorrhoidal Artery Ligation (HAL/RAR)

• Benefits: Better tolerance of the procedure
• Drawback: Higher recurrence rate
• Suitable for: Grade III and IV hemorrhoids 2

Special Considerations

Pregnancy

• Approach: Conservative management preferred
• Medications: Lidocaine-containing products can be safely administered after the first trimester 1

Immunocompromised Patients

• Caution: Increased risk of infection
• Monitoring: Careful follow-up after any procedure 1, 3

Patients on Antithrombotic Agents

• Consideration: May need medication adjustment before surgical intervention
• Risk: Increased bleeding complications 1, 3

Patients with Inflammatory Bowel Disease

• Extreme caution with surgical interventions
• Risks: High rate of postoperative complications including poor wound healing, subsequent proctectomy, abscesses, and fistulas 1

Acutely Thrombosed External Hemorrhoids

• Treatment: Excision of the entire hemorrhoidal mass and overlying skin if within first 2-3 days of symptoms 4, 5

Important caveat: Obsolete treatments to avoid include anal dilation, sphincterotomy, cryosurgery, bipolar diathermy, galvanic electrotherapy, and heat therapy due to poor or missing supporting data. 2