What are the treatment options for hemorrhoids?

Hemorrhoid Treatment Options

The treatment of hemorrhoids should follow a stepwise approach based on the degree of hemorrhoidal disease, with first-line treatment consisting of conservative measures including increased fiber intake (25-30g daily), adequate hydration, sitz baths, and avoidance of straining, followed by procedural interventions for persistent symptoms. 1, 2

Classification of Hemorrhoids

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 1

Treatment Algorithm

1. Conservative Management (All Grades)

• Dietary modifications:

  • Increase fiber intake to 25-30g daily
  • Ensure adequate hydration
  • Regular physical activity to promote bowel regularity 1

• Topical treatments:

  • Sitz baths 2-3 times daily
  • Low-potency topical corticosteroids (hydrocortisone 1%) 3-4 times daily for a maximum of 7 days 1
  • Caution: Prolonged use of topical corticosteroids can cause skin atrophy

• Pharmacological management:

  • Flavonoids (phlebotonics) to improve venous tone and reduce symptoms 1, 2
  • Osmotic laxatives (polyethylene glycol, lactulose) as first-line treatment for constipation
  • Stimulant laxatives (senna, bisacodyl) as second-line treatment if osmotic laxatives are insufficient 1

2. Office-Based Procedures (Grades I-III with persistent symptoms)

• Rubber band ligation:

  • First-line procedural treatment
  • Resolves symptoms in 89% of patients
  • Up to 20% may require repeated procedures 1, 2
  • Should be applied to the mucosa at the anorectal junction, not directly to hemorrhoidal tissue

• Sclerotherapy:

  • Alternative for grades I-II
  • Short-term efficacy of 70-85%
  • Long-term remission in only one-third of patients 1, 2

• Infrared coagulation:

  • Alternative for grades I-II
  • Efficacy of 70-80% in reducing bleeding and prolapse 1, 2

3. Surgical Treatments (Grades III-IV or failed conservative/office procedures)

• Excisional hemorrhoidectomy:

  • Gold standard for grade IV hemorrhoids
  • Low recurrence rates (2-10%)
  • Longer recovery period (9-14 days) 1, 2
  • Ferguson technique (primary closure) appears superior to Milligan-Morgan (open) technique for postoperative pain and wound healing 3

• Stapled hemorrhoidopexy:

  • Alternative for grade III-IV hemorrhoids
  • Less postoperative pain but higher recurrence rates
  • Particularly advisable for circular hemorrhoids 1, 3

• Hemorrhoidal artery ligation:

  • Useful for grade II-III hemorrhoids
  • Less pain and quicker recovery 1

Special Considerations

External Hemorrhoids

• Usually require no specific treatment unless acutely thrombosed
• For thrombosed external hemorrhoids:
  • Outpatient clot evacuation within 72 hours of onset is associated with decreased pain
  • After 72 hours, medical treatment with stool softeners and analgesics is preferred 2, 4

High-Risk Patients

• Immunocompromised patients:

  • Higher infection risk with any procedure
  • Requires careful evaluation and management 1

• Patients with cirrhosis or portal hypertension:

  • Careful evaluation to distinguish from rectal varices
  • Standard hemorrhoidal treatments should not be used for varices 1, 4

• Pregnant women:

  • Conservative management when possible
  • Surgery only if absolutely necessary due to high risk of complications 1

• Patients with inflammatory bowel disease:

  • Extreme caution with surgical interventions
  • High rate of postoperative complications including poor wound healing 1

Post-Treatment Care

• Pain management with NSAIDs
• Fiber supplements
• Sitz baths 2-3 times daily
• Stool softeners to prevent constipation
• Monitor for complications:
  • Bleeding (0.03-6%)
  • Urinary retention (2-36%)
  • Infection (0.5-5.5%)
  • Anal stenosis (0-6%) 1

Common Pitfalls to Avoid

1. Prolonged use of topical corticosteroids beyond 7 days can lead to skin atrophy
2. Failure to distinguish hemorrhoids from other conditions like rectal varices, inflammatory bowel disease, or anorectal malignancy
3. Inappropriate treatment selection based on hemorrhoid grade
4. Inadequate post-procedure care leading to complications
5. Neglecting underlying causes like constipation or straining

The evidence strongly supports a stepwise approach to hemorrhoid management, with conservative measures as first-line treatment for all grades, followed by office-based procedures for persistent symptoms in grades I-III, and surgical interventions reserved for grades III-IV or cases that fail less invasive approaches 1, 2.