From the Guidelines
Hemorrhoids can be effectively treated with non-operative management as first line therapy, focusing on dietary and lifestyle changes, and the administration of flavonoids to relieve symptoms. The most recent and highest quality study, published in 2021 in the World Journal of Emergency Surgery 1, recommends non-operative management as the first line of treatment for complicated hemorrhoids, with a strong recommendation based on moderate quality evidence. This approach includes increasing fiber and water intake, as well as adopting adequate bathroom habits.
Key components of non-operative management include:
- Increasing fiber intake to 25-30 grams daily through foods or supplements like psyllium (Metamucil) 1
- Drinking 6-8 glasses of water daily
- Exercising regularly
- Administering flavonoids to relieve symptoms, as suggested by the 2021 study 1
For immediate relief, patients can use:
- Medicated wipes containing witch hazel (such as Tucks pads) after bowel movements
- Over-the-counter creams or ointments containing hydrocortisone 1% (like Preparation H) up to four times daily for no more than one week
- Warm sitz baths for 15 minutes, 2-3 times daily to reduce swelling and discomfort
- Oral pain relievers such as acetaminophen (Tylenol) or ibuprofen (Advil) as needed, following package directions
Rubber band ligation may be considered for persistent or severe hemorrhoids, as it has been shown to be effective in reducing symptoms and improving patient satisfaction, with success rates varying depending on the degree of hemorrhoids treated and length of follow-up 1. However, this procedure is typically reserved for cases where non-operative management has failed to provide adequate relief.
From the Research
Treatment Options for Hemorrhoids
- Nonprescription topical preparations can be used to treat mild symptoms of hemorrhoids 2
- Medical therapy can be initiated with stool softeners plus local therapy to relieve swelling and symptoms 2
- Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids 2, 3, 4
- For grade 3 hemorrhoids, rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed 2, 5, 4
- Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids 2, 5, 4
- Conservative treatment for low-grade hemorrhoids can consist of fiber supplements and a short course of venotropics 3
- Instrumental treatment such as infrared coagulation or rubber band ligation can be added for prolapsing hemorrhoids 3
- Surgery can be indicated for refractory cases of prolapsing hemorrhoids 3
- Conventional hemorrhoidectomy is the most efficacious intervention for all grades of hemorrhoids 3, 5, 4
- Minimally invasive treatment options such as mucopexy, hemorrhoid artery ligation, and stapled hemorrhoidopexy can be used for grade 3 hemorrhoids 5, 4, 6
- Thrombosed external hemorrhoids can be treated conservatively or excised 2
Surgical Treatment Options
- Excisional hemorrhoidectomy is considered the gold-standard approach for grade IV hemorrhoids 5, 4
- Stapled hemorrhoidopexy is a minimally invasive treatment option that can be used for grade 3 and 4 hemorrhoids 2, 5, 4, 6
- Milligan-Morgan hemorrhoidectomy is considered to be the gold-standard approach for grade IV hemorrhoids 5
- Primary closure (Ferguson) seems to be superior compared to the "open" version (Milligan Morgan) with respect to postoperative pain and wound healing 4
- Hemorrhoidal Artery Ligation (HAL) and Recto-Anal Repair (RAR) are minimally invasive treatment options that can be used for grade 3 and 4 hemorrhoids 4
Non-Surgical Treatment Options
- Fiber enriched diet is the primary treatment option for hemorrhoids 4
- Topical ointments or suppositories and/or flavonoids can be used to treat hemorrhoids 4
- Rubber band ligation is an interventional treatment option for grade I-II hemorrhoids 2, 3, 4
- Infrared coagulation can be used to treat grade I-II hemorrhoids 3
- Sclerosing therapy can be used to treat grade I-II hemorrhoids 4