What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

Conservative management is the first-line treatment for hemorrhoids, including increased fiber intake (25-30g daily), adequate hydration, sitz baths 2-3 times daily, and avoiding straining during defecation. 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

Proper diagnosis requires:

• Careful anorectal examination
• Anoscopy with adequate light source
• Further evaluation with flexible sigmoidoscopy or colonoscopy when bleeding is atypical 1

Note: Anal pain is generally not associated with uncomplicated hemorrhoids and suggests other pathology such as thrombosis, fissure, or abscess 1

Treatment Algorithm

1. Conservative Management (First-line for all grades)

• Dietary modifications:

  • Fiber-enriched diet (25-30g daily)
  • Adequate hydration
  • Avoid straining during defecation 1, 2

• Topical treatments:

  • Sitz baths 2-3 times daily
  • Topical ointments or suppositories (time-limited application) 1, 3

• Medications:

  • Phlebotonics (e.g., flavonoids) to reduce bleeding, pain, and swelling
  • Osmotic laxatives (polyethylene glycol 17g with 8oz water twice daily)
  • Lactulose and magnesium-based products for constipation 1, 2

• Lifestyle changes:

  • Regular physical activity to promote bowel regularity
  • Avoid prolonged sitting 1

2. Office-Based Procedures (For persistent Grade I-III)

If conservative measures fail, proceed to:

• Rubber band ligation (treatment of choice):

  • Resolves symptoms in 89% of patients
  • Up to 20% may require repeated procedures
  • First-line procedural treatment 1, 2, 4

• Alternative procedures:

  • Sclerotherapy: 70-85% short-term efficacy, but only one-third achieve long-term remission
  • Infrared coagulation: 70-80% success in reducing bleeding and prolapse
  • Hemorrhoidal artery ligation: Useful for grade II-III hemorrhoids, with less pain and quicker recovery 1, 2

3. Surgical Management (For Grade III-IV or failed conservative/office treatments)

• Excisional hemorrhoidectomy:

  • Gold standard for grade IV hemorrhoids
  • Low recurrence rate (2-10%)
  • Longer recovery period (9-14 days) 1, 2

• Stapled hemorrhoidopexy:

  • Particularly advisable for circular hemorrhoids
  • Less postoperative pain, shorter operation time and hospital stay
  • Higher recurrence rate compared to excisional hemorrhoidectomy 3

• Hemorrhoidal Artery Ligation (HAL)/Recto-Anal Repair (RAR):

  • Better tolerated procedure
  • Higher recurrence rate 3

Special Situations

Thrombosed External Hemorrhoids

• If within 72 hours of onset: Outpatient clot evacuation
• If more than 72 hours after onset: Medical treatment (stool softeners, oral and topical analgesics) 2

Special Populations

• Immunocompromised patients: Higher infection risk with procedures, requires careful evaluation 1
• Pregnant women: Conservative management preferred, surgery only if absolutely necessary 1
• Patients with inflammatory bowel disease: Extreme caution with surgical interventions due to high rate of complications 1
• Patients with cirrhosis or portal hypertension: Careful evaluation to distinguish from rectal varices 1, 5

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 and Caveats

1. Misdiagnosis: Carefully distinguish hemorrhoids from rectal varices, especially in patients with cirrhosis or portal hypertension 1

2. Overtreatment: Avoid unnecessary surgical interventions when conservative measures may be effective 3

3. Pain misconception: Uncomplicated hemorrhoids typically don't cause significant pain; pain suggests thrombosis, fissure, or abscess 1

4. Delayed colonoscopy: When bleeding is atypical, further evaluation with colonoscopy is essential to rule out more serious conditions 1

5. Inappropriate treatment selection: Treatment should be tailored based on hemorrhoid grade and patient factors 1, 2