What is the treatment for hemorrhoids?

Treatment of Hemorrhoids

The treatment of hemorrhoids should begin with conservative measures including increased fiber intake (25-30g daily), adequate hydration, sitz baths 2-3 times daily, and avoidance of straining during defecation, with procedural interventions reserved for those who fail conservative management. 1

Classification of Hemorrhoids

Hemorrhoids are classified as:

• Internal hemorrhoids (above the dentate line):

  • Grade I: Bleed but do not protrude
  • Grade II: Protrude with defecation but reduce spontaneously
  • Grade III: Protrude and require manual reduction
  • Grade IV: Permanently prolapsed and cannot be reduced

• External hemorrhoids: Located below the dentate line

• Mixed hemorrhoids: Concurrent internal and external hemorrhoidal disease

Treatment Algorithm

First-Line Treatment (All Hemorrhoids)

1. Conservative Management:

   • Increase dietary fiber (25-30g daily) and water intake
   • Sitz baths 2-3 times daily
   • Avoid straining during defecation
   • Avoid prolonged sitting
   • Regular physical activity to promote bowel regularity 1

2. Medication:

   • For constipation: Osmotic laxatives (polyethylene glycol 17g with 8oz water twice daily)
   • For mild to moderate internal hemorrhoids: 5-ASA suppositories at 1g daily 1
   • For non-responders: Hydrocortisone suppositories (5mg prednisolone equivalent) once daily for 1-2 weeks 1
   • Phlebotonics (flavonoids) may reduce bleeding, rectal pain, and swelling 2

Second-Line Treatment (For Persistent Symptoms)

Internal Hemorrhoids (Grade I-III)

• Rubber band ligation: First-line procedural treatment, resolves symptoms in 89% of patients (may require repeated procedures in up to 20%) 1, 2

• Alternative office-based procedures:

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

External Hemorrhoids

• Generally require no specific treatment unless:
  • Acutely thrombosed: Outpatient clot evacuation within 72 hours of onset reduces pain and risk of repeat thrombosis 2
  • Presentation >72 hours after thrombosis: Medical treatment with stool softeners, oral and topical analgesics (5% lidocaine) 2

Third-Line Treatment (Surgical Options)

• Indications for surgery:

  • Grade III-IV hemorrhoids that fail conservative and office-based treatments
  • Mixed hemorrhoidal disease unresponsive to other approaches
  • Complicated hemorrhoids 1, 2

• Surgical options:

  • Excisional hemorrhoidectomy: Gold standard for grade IV hemorrhoids with low recurrence (2-10%) but longer recovery (9-14 days) 1, 2
  • Stapled hemorrhoidopexy: For grade III-IV hemorrhoids, with potentially less pain but risk of rare severe complications 1, 3

Special Considerations

• Pregnant women: Conservative management preferred; surgery only if absolutely necessary 1

• Immunocompromised patients: Higher infection risk with procedures; careful evaluation required 1

• Inflammatory bowel disease: Extreme caution with surgical interventions due to high rate of postoperative complications 1

• Patients on antithrombotic agents: Require special consideration for bleeding risk 4

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%), and anal stenosis (0-6%) 1

Important Diagnostic Considerations

• Anal pain is generally not associated with uncomplicated hemorrhoids and suggests other pathology (thrombosis, fissure, abscess) 1
• Anoscopy is essential for proper evaluation
• Consider colonoscopy for atypical bleeding or when no source is evident on anorectal examination 1