Treatment of Hemorrhoids
The treatment of hemorrhoids should begin with conservative management 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 persistent symptoms. 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
Important diagnostic considerations:
- Anal pain is generally not associated with uncomplicated hemorrhoids and suggests other pathology (thrombosis, fissure, abscess)
- Anoscopy is essential for proper evaluation
- Colonoscopy may be indicated if there are concerns for inflammatory bowel disease or cancer 1
Treatment Algorithm
1. Conservative Management (First-Line)
- Dietary modifications:
- Lifestyle modifications:
- Sitz baths 2-3 times daily
- Avoid straining during defecation
- Avoid prolonged sitting
- Regular physical activity 1
- 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) once daily, typically in the morning 1
- Phlebotonics (flavonoids) can reduce bleeding, pain, and swelling 2
2. Office-Based Procedures (For Grade I-III)
For persistent symptoms despite conservative management:
Rubber band ligation (first-line procedural treatment):
Alternative procedures:
3. Surgical Management
Indicated for:
- Grade III-IV hemorrhoids that fail conservative and office-based treatments
- Mixed hemorrhoidal disease unresponsive to other therapies
- Acutely thrombosed external hemorrhoids (within 72 hours of onset) 1, 2
Surgical options:
- Excisional hemorrhoidectomy: Gold standard for grade IV hemorrhoids, low recurrence (2-10%) but longer recovery (9-14 days) 1, 2
- Stapled hemorrhoidopexy: Less postoperative pain, shorter recovery time, but higher recurrence rate 3
- Closed hemorrhoidectomy: Effective for large prolapsing or acutely thrombosed hemorrhoids 4
Special Considerations
Thrombosed External Hemorrhoids
- If within 72 hours of onset: Outpatient clot evacuation
- If more than 72 hours: Medical treatment (stool softeners, oral and topical analgesics) 2
High-Risk Patients
- Immunocompromised patients: Higher infection risk with procedures, requires careful evaluation 1
- Pregnant women: Conservative management preferred, surgery only if absolutely necessary 1
- Inflammatory bowel disease: Extreme caution with surgical interventions due to high rate of complications 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%) 1
Common Pitfalls
- Treating asymptomatic hemorrhoids unnecessarily
- Failing to rule out other causes of rectal bleeding
- Jumping to procedural interventions before adequate trial of conservative management
- Not recognizing when anal pain indicates complications or other conditions
- Inadequate post-procedure pain management
The French Society of Colo-Proctology emphasizes that medical treatment should always be proposed first, with instrumental treatment only if medical treatment fails (except in grade ≥III prolapse), and surgery as the last resort 5.