What are the management options for hemorrhoids?

Management of Hemorrhoids

The management of hemorrhoids should follow a stepwise approach based on hemorrhoid grade, with conservative measures as first-line treatment for early stages and surgical 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 and cannot be reduced 2, 1

Proper diagnosis requires:

• External examination
• Anoscopy with adequate light source
• Assessment for concomitant conditions (e.g., anal fissures) 1
• Sigmoidoscopy for all patients reporting rectal bleeding
• Colonoscopy or barium enema for atypical bleeding patterns or risk factors for colorectal cancer 2

Treatment Algorithm

Conservative Management (First-Line for All Grades)

1. Dietary and Lifestyle Modifications:

   • High-fiber diet (25-30g daily)
   • Increased water intake (8-10 glasses daily)
   • Regular physical activity
   • Avoiding prolonged sitting on the toilet 1, 3

2. Pharmacological Therapy:

   • Phlebotonics (flavonoids) for symptom relief
   • Topical corticosteroids for perianal skin irritation (limited to 7 days maximum) 1, 2
   • Stool softeners and analgesics as needed 3

Procedural Interventions (For Persistent Symptoms)

Based on hemorrhoid grade:

First-degree Hemorrhoids:

• Continue conservative management
• If failed: Consider sclerotherapy or infrared coagulation 2, 3

Second-degree Hemorrhoids:

• Rubber band ligation (preferred office procedure, 80% success rate)
• Alternatives: Sclerotherapy (89.9% improvement but 30% recurrence at 4 years) 1, 3

Third-degree Hemorrhoids:

• Office procedures first (rubber band ligation)
• If failed: Consider surgical intervention 1

Fourth-degree Hemorrhoids:

• Surgical intervention required 1, 3

Surgical Management

Indications for surgery:

1. Failure of medical and non-operative therapy
2. Symptomatic third-degree, fourth-degree, or mixed hemorrhoids
3. Complicated hemorrhoids 2

Surgical options:

• Excisional hemorrhoidectomy: Gold standard with lowest recurrence rate (2-10%) but more painful recovery (9-14 days) 1, 3
• Stapled hemorrhoidopexy: Alternative with less postoperative pain but higher recurrence rate 1
• Hemorrhoidal Artery Ligation (HAL): Better tolerated but higher recurrence rate 4

Special Considerations

Thrombosed External Hemorrhoids

• Early presentation (<72 hours): Excision under local anesthesia
• Late presentation (>72 hours): Conservative management as pain typically resolves after 7-10 days 2, 3

High-Risk Populations

• Pregnant women: Conservative management preferred; surgery only if absolutely necessary 1
• Immunocompromised patients: Higher risk for infection, especially after rubber band ligation 2, 1
• Patients on anticoagulants: May need medication adjustment before procedures 1
• Patients with IBD: Extreme caution with surgical interventions due to high complication rates 1
• Cirrhosis/portal hypertension: Distinguish from rectal varices, which require different management 1

Complications of Surgical Treatment

• Postoperative pain (significant)
• Bleeding (0.03-6%)
• Urinary retention (2-36%)
• Infection (0.5-5.5%)
• Anal stenosis (0-6%)
• Incontinence (2-12%) 1

Postoperative Care

• Pain management with NSAIDs and narcotics as needed
• Fiber supplements
• Topical antispasmodics
• Sitz baths 2-3 times daily
• Stool softeners 1

Remember that surgical hemorrhoidectomy should be recommended only for a small minority of patients due to its association with significantly more pain and complications than non-operative techniques 2.