What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The most effective approach to hemorrhoid management begins with conservative measures including increased fiber intake (25-30g daily), adequate hydration, and sitz baths, followed by procedural interventions such as rubber band ligation for persistent symptoms, with surgery reserved for advanced cases. 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:

• Anoscopy for routine examination
• Imaging studies if suspecting anorectal abscess, inflammatory bowel disease, or neoplasm
• Colonoscopy for patients with risk factors for colorectal cancer (e.g., adults over 50 years) 1, 2

Treatment Algorithm

First-Line: Conservative Management

• Increase dietary fiber to 25-30g daily
• Ensure adequate hydration
• Take sitz baths 2-3 times daily
• Avoid straining during defecation
• Avoid prolonged sitting
• Engage in regular physical activity 1, 3

For constipation management:

• Bulk-forming agents (psyllium husk, methylcellulose)
• Osmotic laxatives (polyethylene glycol, lactulose) when needed 1

Second-Line: Topical and Medical Treatments

• Mesalamine (5-ASA) suppositories (most effective option per American Gastroenterological Association)
• Hydrocortisone suppositories for short-term management
• Topical treatments (patches preferred over creams/ointments)
• Phlebotonics (flavonoids) can reduce bleeding, pain, and swelling 1, 3

Third-Line: Office-Based Procedures

For grades I-III internal hemorrhoids that fail conservative management:

1. Rubber band ligation:

   • First-line procedural treatment
   • 89% success rate (though 20% may need repeated procedures)
   • Places band around hemorrhoid base to restrict blood flow 1, 3

2. Sclerotherapy:

   • 70-85% short-term efficacy
   • Only one-third achieve long-term remission
   • Involves injection of sclerosant to induce fibrosis 1, 3

3. Infrared coagulation:

   • 70-80% success in reducing bleeding and prolapse
   • Uses heat to coagulate hemorrhoidal tissue 1, 3

4. Hemorrhoidal artery ligation:

   • Useful for grade II-III hemorrhoids
   • Less pain and quicker recovery 1

Fourth-Line: Surgical Management

Indicated for:

• Grade III-IV hemorrhoids
• Failed conservative and office-based treatments
• Mixed hemorrhoidal disease
• Complicated cases 1, 3

Surgical options:

• Excisional hemorrhoidectomy: Gold standard for grade IV, low recurrence (2-10%), but longer recovery (9-14 days)
• Ligasure hemorrhoidectomy: Minimally invasive alternative
• Stapled hemorrhoidopexy: For internal hemorrhoids, requires thorough surgical training 1, 4, 5

Special Situations

Thrombosed External Hemorrhoids

• If within 72 hours of onset: Outpatient clot evacuation (reduces pain and risk of repeat thrombosis)
• If beyond 72 hours: Medical management with stool softeners, oral and topical analgesics (5% lidocaine) 3, 2

Pregnant Women

• Prioritize conservative management
• Bulk-forming agents and osmotic laxatives are safe
• Topical hydrocortisone preparations are effective and safe
• Surgery only if absolutely necessary due to high complication risk 1

Immunocompromised Patients

• Higher infection risk with procedures
• Requires careful evaluation and management 1

Patients with Liver Cirrhosis/Portal Hypertension

• Special caution needed to distinguish anal varices from hemorrhoids 1

Patients on Antithrombotic Agents

• Requires careful consideration of bleeding risk
• May need temporary medication adjustment for procedures 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%), anal stenosis (0-6%) 1

Common Pitfalls

1. Misattributing anorectal symptoms to hemorrhoids when other conditions may be present
2. Failing to consider colonoscopy for patients with rectal bleeding who are at risk for colorectal cancer
3. Using intravenous lidocaine simultaneously with topical lidocaine (risk of toxicity)
4. Applying rubber bands directly to hemorrhoidal tissue instead of to the mucosa at the anorectal junction
5. Attempting surgical interventions in patients with inflammatory bowel disease without proper precautions 1, 2, 6