What is the first line treatment for hemorrhoids?

First-Line Treatment for Hemorrhoids

The first-line treatment for hemorrhoids is conservative management with increased dietary fiber intake (25-30g daily), adequate hydration, sitz baths 2-3 times daily, avoidance of straining during defecation, and topical treatments for symptomatic relief. 1, 2

Initial Assessment and Classification

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

Conservative Management (First-Line)

Dietary and Lifestyle Modifications

• Increase fiber intake to 25-30g daily
• Ensure adequate hydration
• Avoid straining during defecation
• Avoid prolonged sitting
• Engage in regular physical activity to promote bowel regularity 1

Topical Treatments

• Topical treatments are recommended for temporary relief of pain, burning, and itching 1
• Hydrocortisone suppositories are effective for short-term management of inflammation and discomfort 1
• Patches with 4% or 5% lidocaine are more effective than cream or ointment due to gradual delivery over hours 1

Bulk-Forming Agents

• Psyllium husk or methylcellulose can be used to improve stool consistency
• Osmotic laxatives such as polyethylene glycol (PEG) or lactulose may be used when appropriate 1

Medical Treatment (When Conservative Measures Are Insufficient)

• Mesalamine (5-ASA) suppositories are recommended by the American Gastroenterological Association as the most effective option for patients with hemorrhoids (RR 0.44,95% CI 0.34-0.56) 1
• Phlebotonics (e.g., flavonoids) can reduce bleeding, rectal pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after treatment cessation 2, 3

Procedural Treatment (For Persistent Symptoms)

When conservative and medical treatments fail, procedural interventions may be considered:

• Rubber band ligation is the first-line procedural treatment for grades I-III internal hemorrhoids, resolving symptoms in 89% of patients 1, 2
• Sclerotherapy (70-85% short-term efficacy) and infrared coagulation (70-80% efficacy) are alternatives for grades I-II 1
• Hemorrhoidal artery ligation is useful for grade II-III hemorrhoids 1
• Excisional hemorrhoidectomy is indicated for grade III-IV hemorrhoids that fail less invasive treatments 1, 2

Special Considerations

Thrombosed External Hemorrhoids

• Outpatient clot evacuation within 72 hours of onset is associated with decreased pain and reduced risk of repeat thrombosis
• After 72 hours, medical treatment with stool softeners and analgesics is preferred 2

Pregnancy

• Conservative management is preferred when possible
• Topical hydrocortisone preparations are safe and effective in pregnant women 1

Common Pitfalls to Avoid

1. Misdiagnosis: Anorectal symptoms are often misattributed to hemorrhoids when other conditions may be present. Consider anoscopy for proper diagnosis 1

2. Overtreatment: Not all hemorrhoids require procedural intervention. Many patients respond well to conservative measures alone 1, 2

3. Inadequate fiber supplementation: Patients often don't consume enough fiber to see benefits. Ensure intake reaches 25-30g daily 1

4. Ignoring underlying causes: Chronic constipation, prolonged sitting, and other lifestyle factors should be addressed to prevent recurrence 1

5. Prolonged use of topical steroids: Hydrocortisone suppositories should only be used short-term due to potential safety concerns 1

Conservative management should be given adequate time (typically 2-4 weeks) before considering procedural interventions, as many patients will experience significant improvement with these measures alone.