What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

Treatment of hemorrhoids should be guided by their severity, with conservative management as first-line for early stages and procedural interventions reserved for advanced or refractory cases. 1, 2

Classification and Diagnosis

Hemorrhoids are classified into four degrees:

• First-degree: Bleed but do not protrude
• Second-degree: Protrude with defecation but reduce spontaneously
• Third-degree: Protrude and require manual reduction
• Fourth-degree: Permanently prolapsed, cannot be reduced

External hemorrhoids typically only cause symptoms when thrombosed, resulting in acute pain.

Treatment Algorithm

Conservative Management (First-line for all hemorrhoids)

• Dietary modifications:
  • High-fiber diet (25-30g daily)
  • Increased water intake (8-10 glasses daily)
  • Bulk-forming agents (psyllium husk)
• Lifestyle changes:
  • Regular physical activity
  • Avoiding prolonged toilet sitting
  • Following "TONE" principles: Three minutes at defecation, Once-a-day defecation frequency, No straining, Enough fiber 3
• Topical treatments:
  • Low-potency corticosteroids (e.g., hydrocortisone 1%) for perianal irritation (limit to 7 days)
  • Analgesics for pain relief
  • Phlebotonics (flavonoids) for symptom improvement 2, 4

Non-operative Procedures (For first to third-degree hemorrhoids)

• Rubber band ligation:
  • First-choice office procedure for second and third-degree hemorrhoids
  • Success rate: 89% symptom resolution
  • Lowest recurrence rate among non-operative techniques
  • Applied to mucosa at anorectal junction, not directly to hemorrhoidal tissue 1, 5
• Injection sclerotherapy:
  • For first and second-degree hemorrhoids
  • Higher relapse rate than banding
  • Short-term efficacy: 70-85% 1, 4
• Other techniques:
  • Infrared coagulation: 70-80% success in reducing bleeding and prolapse
  • Bipolar coagulation
  • Diathermy coagulation
  • Note: Cryotherapy is no longer recommended due to high complication rates 1

Surgical Management

• Indications for hemorrhoidectomy:

  1. Failure of medical and non-operative therapy
  2. Symptomatic third or fourth-degree hemorrhoids
  3. Mixed internal and external hemorrhoids
  4. Concomitant anorectal condition requiring surgery 1

• Surgical options:

  • Excisional hemorrhoidectomy:
    • Gold standard for advanced hemorrhoids
    • Success rate: 90-98%
    • Recurrence rate: 2-10%
    • Drawback: More postoperative pain 2, 4
  • Stapled hemorrhoidopexy:
    • Less painful than conventional hemorrhoidectomy
    • Higher recurrence rate
    • Not ideal for gangrenous or thrombosed hemorrhoids 2

Special Situations

• Thrombosed external hemorrhoids:

  • If diagnosed early (<72 hours): Excision under local anesthesia
  • If symptoms resolving (>72 hours): Conservative management with stool softeners and analgesics
  • Pain typically resolves in 7-10 days without intervention 1, 4

• Immunocompromised patients:

  • Higher risk for infection, particularly after rubber band ligation
  • Requires careful perioperative management 1, 2

• Pregnant women:

  • Conservative management preferred
  • Surgery only if absolutely necessary 2

• Patients on anticoagulants:

  • May require medication adjustment before procedures 2

Complications of Surgical Treatment

• Postoperative pain (most common)
• Bleeding (0.03-6%)
• Urinary retention (2-36%)
• Infection (0.5-5.5%)
• Anal stenosis (0-6%)
• Incontinence (2-12%) 2

Efficacy of Conservative Approach

Adequate fiber supplementation combined with proper defecation habits can prevent progression of hemorrhoids and reduce bleeding episodes, potentially avoiding surgery in up to 87% of patients with advanced hemorrhoids 3.