What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

First-line treatment for hemorrhoids should include increased fiber intake (25-30g daily), adequate hydration, sitz baths 2-3 times daily, avoidance of straining during defecation, and avoidance of prolonged sitting. 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 1

Diagnostic approach includes:

• Anoscopy for routine physical examination
• Imaging studies when suspecting anorectal abscess or other conditions
• Colonoscopy when concerned about inflammatory bowel disease or cancer 1

Treatment Algorithm

1. Conservative Management

• Dietary modifications:
  • Increase fiber intake to 25-30g daily
  • Ensure adequate hydration
  • Consider bulk-forming agents like psyllium husk 1, 2
• Behavioral measures:
  • Sitz baths 2-3 times daily
  • Regular physical activity to promote bowel regularity
  • Avoid prolonged sitting and straining during defecation 1
• TONE approach (particularly effective for advanced hemorrhoids):
  • T: Three minutes at defecation
  • O: Once-a-day defecation frequency
  • N: No straining during passing motions
  • E: Enough fiber 2
• Laxatives for constipation:
  • Osmotic laxatives (polyethylene glycol, lactulose) as first-line
  • Stimulant laxatives (senna, bisacodyl) as second-line if needed 1

2. Topical Treatments

• For itching and discomfort:
  • Low-potency corticosteroids (1% hydrocortisone) 3-4 times daily
  • Maximum duration: 7 days to avoid skin atrophy
  • Avoid triamcinolone for routine hemorrhoid itching 1
• For pain relief:
  • Topical analgesics (5% lidocaine) 3

3. Office-Based Procedures (for Grade I-III)

• Rubber band ligation:
  • First-line procedural treatment
  • Success rate: 89% (though 20% may require repeated procedures)
  • Apply to mucosa at anorectal junction, not directly to hemorrhoidal tissue 1, 4, 5
• Sclerotherapy:
  • Alternative for grades I-II
  • Short-term efficacy: 70-85%
  • Long-term remission: only one-third of patients 1, 4
• Infrared coagulation:
  • Alternative for grades I-II
  • Efficacy: 70-80% in reducing bleeding and prolapse 1, 4
• Hemorrhoidal artery ligation:
  • Useful for grade II-III hemorrhoids
  • Less pain and quicker recovery 1

4. Surgical Interventions (for Grade III-IV or Failed Conservative Treatment)

• Excisional hemorrhoidectomy:
  • Gold standard for grade IV hemorrhoids
  • Low recurrence rates (2-10%)
  • Longer recovery period (9-14 days) 1, 4
• Stapled hemorrhoidopexy:
  • Alternative for grade III-IV hemorrhoids
  • Less postoperative pain but higher recurrence rates 1
• Closed hemorrhoidectomy:
  • Effective for large prolapsing or acutely thrombosed hemorrhoids
  • Advantages: rapid healing and minimal postoperative care 5

Special Considerations

External Hemorrhoids

• Usually require no specific treatment unless acutely thrombosed
• For thrombosed external hemorrhoids:
  • Outpatient clot evacuation within 72 hours of onset
  • After 72 hours: medical treatment with stool softeners and analgesics 4, 6

High-Risk Patients

• Immunocompromised patients: Higher infection risk with procedures 1
• Cirrhosis/portal hypertension: Careful evaluation to distinguish from rectal varices 1, 6
• Pregnancy: Conservative management preferred; surgery only if absolutely necessary 1
• Inflammatory bowel disease: Extreme caution with surgical interventions due to high complication rates 1
• Patients on antithrombotic agents: Require special consideration 6

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%) 1

Common Pitfalls to Avoid

1. Using potent corticosteroids for extended periods (can cause skin atrophy)
2. Applying rubber bands directly to hemorrhoidal tissue rather than mucosa
3. Delaying treatment of thrombosed external hemorrhoids beyond 72 hours
4. Failing to distinguish rectal varices from hemorrhoids in cirrhotic patients
5. Neglecting dietary and lifestyle modifications before pursuing invasive treatments