What is the management for thrombosed hemorrhoids?

Management of Thrombosed Hemorrhoids

For thrombosed external hemorrhoids, surgical excision of the entire hemorrhoidal mass and overlying skin is the recommended treatment, as it is associated with significantly lower recurrence rates compared to conservative management. 1

Diagnosis and Evaluation

• A careful anorectal examination is essential for accurate diagnosis of thrombosed hemorrhoids 2
• Key diagnostic features of thrombosed hemorrhoids:
  • Acute onset of severe anal pain
  • Visible bluish lump at the anal verge
  • Firm, tender swelling on examination
• Thrombosed hemorrhoids must be distinguished from other causes of anal pain such as anal fissures or abscesses 2

Treatment Algorithm

Timing Considerations

• Excision is most effective when performed within the first 2-3 days of symptom onset 3
• After 72 hours, the benefits of surgical excision diminish as the thrombus begins to resolve naturally

First-Line Treatment: Surgical Excision

• Excision of the entire hemorrhoidal mass with the overlying skin provides the most effective pain relief 4
• Technique:
  1. Local anesthesia with lidocaine (with or without epinephrine)
  2. Elliptical incision over the thrombosed hemorrhoid
  3. Complete removal of the thrombus and hemorrhoidal tissue
  4. Wound may be left open to heal by secondary intention

Conservative Management (Alternative Approach)

If surgery is not feasible or if presentation is beyond 72 hours:

• Topical analgesics containing lidocaine or hydrocortisone
• Regular sitz baths (2-3 times daily for 10-15 minutes)
• Oral analgesics (NSAIDs preferred)
• Stool softeners and increased fiber intake (25-30g daily)
• Adequate hydration and avoidance of straining 2

Evidence Comparison and Strength

The most recent and highest quality evidence from a 2025 systematic review and meta-analysis demonstrates that surgical treatment is associated with a significantly lower risk of recurrence compared to conservative management (RR 0.49; 95% CI 0.26-0.91) 1. This strongly supports surgical excision as the preferred approach for thrombosed external hemorrhoids.

Earlier research from 2018 also supports excision within the first 2-3 days of symptoms to provide the greatest pain relief 3, consistent with findings from 2009 that excision is the most effective treatment for thrombosed external hemorrhoids 4.

Post-Treatment Care

• Pain management with NSAIDs
• Sitz baths 2-3 times daily
• Fiber supplements (25-30g daily)
• Adequate hydration
• Stool softeners to prevent constipation
• Avoidance of straining during defecation
• Monitor for complications such as bleeding or infection 2

Prevention of Recurrence

• Increased dietary fiber intake
• Adequate fluid intake
• Regular physical activity
• Avoiding prolonged sitting on the toilet
• Prompt treatment of constipation 2

Common Pitfalls to Avoid

1. Delayed treatment - Pain relief is maximized when excision is performed within the first 72 hours
2. Incomplete excision - Failure to remove the entire thrombosed hemorrhoid can lead to persistent symptoms
3. Misdiagnosis - Ensure the condition is truly a thrombosed hemorrhoid and not another anorectal condition
4. Inadequate post-procedure care - Proper wound care and bowel management are essential to prevent complications

Remember that anal pain is generally not associated with uncomplicated hemorrhoids and suggests thrombosis, fissure, or abscess, highlighting the importance of careful evaluation to distinguish between different conditions 2.