What are the management options for hemorrhoids?

From the Guidelines

Hemorrhoid management should start with non-operative management as first-line therapy, focusing on dietary and lifestyle changes, such as increased fiber and water intake, and adequate bathroom habits, as recommended by the most recent guidelines 1. The goal of these changes is to reduce symptoms and prevent further complications.

• Increasing fiber intake to 25-30g daily through diet or supplements like psyllium (Metamucil) or methylcellulose (Citrucel) can help soften stool and reduce straining during bowel movements.
• Drinking 6-8 glasses of water daily can also help prevent constipation and reduce pressure on the rectal veins.
• Avoiding straining during bowel movements and taking regular breaks to stretch and move around can also help reduce pressure on the rectal veins.

For patients with complicated hemorrhoids, flavonoids may be administered to relieve symptoms, although the evidence is moderate and the recommendation is weak 1. Additionally, topical muscle relaxants may be used for thrombosed or strangulated hemorrhoids, but the evidence is low-quality and the recommendation is weak 1. It's essential to note that no recommendation can be made regarding the role of NSAIDs, topical steroids, other topical agents, or injection of local anesthetics for complicated hemorrhoids, based on the available literature 1.

In terms of medical procedures, hemorrhoidectomy is the most effective treatment for hemorrhoids but is associated with significantly more pain and complications than nonoperative techniques, and should only be recommended for a small minority of patients 1. Indications for elective hemorrhoidectomy include failure of medical and nonoperative therapy, symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids, symptomatic hemorrhoids in the presence of a concomitant anorectal condition that requires surgery, and patient preference after discussion of treatment options 1. Nonoperative techniques, such as rubber band ligation, sclerotherapy, and infrared coagulation, may be used for outpatients and can be repeated as needed, with complications being infrequent and usually minor 1.

From the Research

Management Options for Hemorrhoids

The management of hemorrhoids can be divided into non-surgical and surgical options.

• Non-surgical options include:
  • Medical therapy with stool softeners and local therapy to relieve swelling and symptoms 2
  • Rubber band ligation, which is the treatment of choice for grades 1 and 2 hemorrhoids 2, 3, 4
  • Sclerotherapy, which can be used to treat grade 1 and 2 internal hemorrhoids 5
  • Conservative treatment based on dietary and lifestyle changes 4
• Surgical options include:
  • Excisional hemorrhoidectomy, which is recommended for treatment of grade 4 hemorrhoids 2, 4
  • Stapled hemorrhoidopexy, which can be performed in patients with grade 3 hemorrhoids and has a faster postoperative recovery, but a higher recurrence rate 2, 3
  • Milligan-Morgan hemorrhoidectomy, which is considered to be the gold-standard approach for grade IV hemorrhoids 4
  • Minimally invasive treatment options, such as mucopexy with or without mucosal resection and hemorrhoid artery ligation, which can be used to manage grade III hemorrhoids 4
  • Ligasure hemorrhoidectomy and doppler-guided hemorrhoidal artery ligation, which are minimally invasive operations that can be used to treat hemorrhoids 3

Treatment of Specific Types of Hemorrhoids

• Internal hemorrhoids:
  • Can be treated with rubber band ligation, sclerotherapy, or injection sclerotherapy for low-graded hemorrhoids 2, 3, 5
  • May require surgical intervention for high-graded hemorrhoids or when non-operative approaches have failed 2, 3
• External hemorrhoids:
  • Usually require no specific treatment unless they become acutely thrombosed or cause patient discomfort 3
  • Can be treated conservatively or excised if thrombosed 2
• Thrombosed external hemorrhoids:
  • Can be treated conservatively or excised 2