What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The treatment of hemorrhoids should follow a stepwise approach based on severity, with first-line management consisting of conservative measures including increased fiber intake (25-30g daily), adequate hydration (8-10 glasses daily), and phlebotonics (flavonoids), reserving surgical intervention primarily for third or fourth-degree hemorrhoids that fail conservative management. 1

Classification and Diagnosis

Proper diagnosis is essential before initiating treatment. Hemorrhoids are classified into four degrees:

• 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 includes:

• External examination
• Anoscopy (routine)
• Imaging studies (if suspecting anorectal abscess, IBD, or neoplasm)
• Colonoscopy (if concerns for IBD or cancer) 1

Treatment Algorithm

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

• Dietary modifications:

  • High-fiber diet (25-30g daily)
  • Increased water intake (8-10 glasses daily)
  • Avoid straining during defecation 1, 2

• Lifestyle modifications:

  • Regular physical activity
  • Avoid prolonged sitting on toilet 1

• Pharmacological treatment:

  • Phlebotonics (flavonoids): Reduce bleeding, rectal pain, and swelling
    • Note: Symptom recurrence reaches 80% within 3-6 months after treatment cessation 2
  • Topical treatments: Low-potency corticosteroids (e.g., hydrocortisone 1%)
    • Limit use to maximum 7 days to avoid skin/mucosal atrophy 1

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

• Rubber band ligation:

  • Preferred office procedure for second-degree hemorrhoids
  • Success rate: 80% improvement, 69% symptom-free at 5-year follow-up
  • Complications: Pain (5-60% of patients), minor bleeding, rarely necrotizing pelvic sepsis
  • Follow-up: Evaluate 1-2 weeks after procedure 1, 2

• Sclerotherapy:

  • Alternative for first/second-degree hemorrhoids
  • Success rate: 89.9% improvement/cure initially
  • Drawback: Higher recurrence rate (30% at 4 years) 1

• Infrared coagulation:

  • 70-80% success in reducing bleeding and prolapse 2

3. Surgical Management (For Grade III-IV or Failed Office Procedures)

• Indications for surgery:

  • Third or fourth-degree hemorrhoids
  • Hemorrhoids too extensive for non-operative management
  • Failure of conservative management
  • Patient preference
  • Concomitant conditions requiring surgery
  • Thrombosed, gangrenous, or incarcerated hemorrhoids 1

• Surgical techniques:

  • Excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson)

    • Benefits: Definitive treatment, low recurrence rates (2-10%)
    • Risks: Postoperative pain, urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), incontinence (2-12%)
    • Recovery: 9-14 days 1, 2

  • Stapled hemorrhoidopexy (PPH/Longo procedure):

    • Benefits: Less postoperative pain, shorter operation time/hospital stay, faster recovery
    • Drawback: Higher recurrence rate compared to conventional techniques 1

  • Hemorrhoidal Artery Ligation (HAL):

    • Better tolerated but higher recurrence rate 1

4. Special Considerations for External Hemorrhoids

• Thrombosed external hemorrhoids:
  • If within 72 hours of onset: Outpatient clot evacuation (reduces pain and risk of repeat thrombosis)
  • If >72 hours after thrombosis: Medical treatment (stool softeners, oral/topical analgesics) 2

Special Patient Populations

Exercise caution in:

• Pregnant women: Lidocaine-containing products safe after first trimester
• Immunocompromised patients: Increased infection risk
• Patients with IBD: High rate of postoperative complications
• Patients on anticoagulants: May need medication adjustment
• Patients with portal hypertension/cirrhosis: Requires careful evaluation 1

Common Pitfalls and Caveats

1. Misdiagnosis: Always rule out other causes of symptoms (anal fissures, abscesses, rectal varices)

2. Overtreatment: Only 5-10% of hemorrhoid patients require surgical intervention 1

3. Inappropriate surgical candidate selection: Surgery should be reserved for higher-grade hemorrhoids or those failing conservative management

4. Inadequate follow-up: Evaluate for symptom improvement after procedures, especially rubber band ligation

5. Prolonged use of topical steroids: Limit to 7 days maximum to prevent complications 1

6. Neglecting conservative measures: Always start with dietary and lifestyle modifications before progressing to more invasive treatments

7. Ignoring special populations: Patients with IBD, pregnancy, or on anticoagulants require modified approaches 1