What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The cornerstone of hemorrhoid treatment is a high-fiber diet (25-30g daily) and increased water intake (8-10 glasses daily), which should be recommended as first-line therapy for all patients with hemorrhoids. 1

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

External hemorrhoids usually cause symptoms only when thrombosed, resulting in acute pain 2.

Treatment Algorithm

First-Line: Conservative Management

• Dietary modifications:

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

• Topical treatments for symptomatic relief:

  • Low-potency topical corticosteroids (hydrocortisone 1%) for perianal irritation, applied 3-4 times daily for maximum 7 days
  • Avoid prolonged use of potent corticosteroids due to risk of skin atrophy 2, 1

• Oral medications:

  • Phlebotonics (flavonoids) can improve venous tone and reduce bleeding, pain, and swelling
  • Note: Symptom recurrence can reach 80% within 3-6 months after treatment cessation 1, 3

Second-Line: Office-Based Procedures

For first to third-degree hemorrhoids when conservative management fails:

• Rubber band ligation:

  • Treatment of choice for second-degree hemorrhoids
  • Success rate of 80% improvement and 69% symptom-free at 5-year follow-up
  • Most effective non-operative technique with lowest recurrence rate 2, 1

• Sclerotherapy:

  • Alternative for first and second-degree hemorrhoids
  • 89.9% improvement or cure initially
  • Higher recurrence rate (30% at 4 years) compared to rubber band ligation 1

• Infrared coagulation:

  • 70-80% success in reducing bleeding and prolapse
  • Less effective long-term than rubber band ligation 3

Third-Line: Surgical Management

For third and fourth-degree hemorrhoids, failed non-operative management, or complications:

• Excisional hemorrhoidectomy:

  • Gold standard with lowest recurrence rate (2-10%)
  • More painful recovery (9-14 days)
  • Indicated for: failure of non-operative therapy, symptomatic third/fourth-degree hemorrhoids, mixed hemorrhoids, or when other anorectal conditions require surgery 2, 1, 3

• Stapled hemorrhoidopexy:

  • Less postoperative pain than conventional hemorrhoidectomy
  • Higher recurrence rate
  • Not ideal for gangrenous or thrombosed incarcerated hemorrhoids 2, 1

Special Considerations

Thrombosed External Hemorrhoids

• If diagnosed early (within 72 hours of onset), excision under local anesthesia is recommended
• For patients presenting after 72 hours with resolving symptoms, conservative management is appropriate as pain typically resolves after 7-10 days 2, 3

High-Risk Patients

• Immunocompromised patients: Higher risk for infection, especially after procedures like rubber band ligation 2, 1
• Cirrhosis/portal hypertension: Require distinction from rectal varices, which need different management 1
• Pregnant women: Conservative management preferred; surgery only if absolutely necessary 1
• Inflammatory bowel disease: Extreme caution with surgical interventions due to high rate of complications 1

Potential Complications of Surgical Treatment

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

Common Pitfalls to Avoid

1. Overuse of topical corticosteroids: Limit to 7 days to prevent skin atrophy
2. Manual anal dilatation: Not recommended due to risk of sphincter injury and incontinence 2
3. Treating hemorrhoids without proper diagnosis: Always rule out other causes of rectal bleeding through appropriate visualization techniques 1
4. Recommending surgery as first-line treatment: Surgery should be reserved for a small minority of patients due to higher pain and complication rates 2, 1
5. Neglecting fiber supplementation: Essential for both treatment and prevention of recurrence 2, 1

The treatment approach should follow a stepwise progression from conservative measures to more invasive options based on hemorrhoid severity and response to previous treatments, always prioritizing patient comfort and minimizing complications.