What is the treatment for non-thrombosed hemorrhoids?

Treatment for Non-Thrombosed Hemorrhoids

For non-thrombosed hemorrhoids, first-line treatment consists of conservative management with increased dietary fiber (25-30g daily), adequate hydration, sitz baths 2-3 times daily, and avoidance of straining during defecation. 1

Classification and Initial Assessment

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

It's important to note that many anorectal symptoms are often misattributed to hemorrhoids, so a thorough diagnostic evaluation including anoscopy is necessary to confirm the diagnosis and rule out other conditions 1.

Treatment Algorithm

Step 1: Conservative Management (All Grades)

• Dietary modifications:

  • Increase fiber intake to 25-30g daily
  • Ensure adequate hydration (at least 8 glasses of water daily)
  • Bulk-forming agents like psyllium husk or methylcellulose can be added 1, 2

• Lifestyle modifications:

  • Avoid straining during defecation
  • Avoid prolonged sitting on the toilet
  • Regular physical activity to promote bowel regularity 1

• Symptomatic relief:

  • Sitz baths 2-3 times daily for 10-15 minutes
  • Topical treatments for pain, burning, and itching 1
  • Phlebotonics (flavonoids) may reduce bleeding, rectal pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after stopping treatment 2

Step 2: Medical Treatment (If Conservative Management Fails)

• Topical treatments:
  • Mesalamine (5-ASA) suppositories are recommended as most effective (superior to placebo with RR 0.44,95% CI 0.34-0.56) 1
  • Hydrocortisone suppositories for short-term management to reduce inflammation and relieve symptoms 1
  • Patches with 4-5% lidocaine are more effective than cream or ointment due to gradual delivery over hours 1

Step 3: Procedural Interventions (Grades I-III)

If symptoms persist despite conservative and medical therapy:

• Rubber band ligation: First-line procedural treatment

  • Resolves symptoms in 89% of patients
  • Up to 20% may require repeated procedures
  • Most appropriate for grade I-III hemorrhoids 1, 2

• Sclerotherapy:

  • Short-term efficacy of 70-85%
  • Long-term remission in only one-third of patients 1, 2

• Infrared coagulation:

  • 70-80% success in reducing bleeding and prolapse 1, 2

• Hemorrhoidal artery ligation:

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

Step 4: Surgical Management (Grades III-IV)

• Excisional hemorrhoidectomy:

  • Gold standard for grade IV hemorrhoids
  • Indicated when non-operative approaches have failed
  • Low recurrence rate (2-10%)
  • Longer recovery period (9-14 days) 1, 2

• Stapled hemorrhoidopexy:

  • Alternative for circular hemorrhoids
  • Associated with reduced postoperative pain, shorter operation time and hospital stay
  • Higher recurrence rate compared to excisional hemorrhoidectomy 3

Post-Treatment Care

• Pain management with NSAIDs
• Continued 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

Special Considerations

• Pregnant women: Conservative management is preferred; surgery only if absolutely necessary 1
• Immunocompromised patients: Higher infection risk with procedures 1
• Patients with inflammatory bowel disease: Extreme caution with surgical interventions due to high rate of postoperative complications 1
• Patients with liver cirrhosis or portal hypertension: Special caution to distinguish anal varices from hemorrhoids 1

Common Pitfalls to Avoid

1. Misdiagnosis: Ensure proper diagnosis with anoscopy, as many anorectal symptoms are misattributed to hemorrhoids 1
2. Premature procedural intervention: Exhaust conservative options before moving to procedures 1, 2
3. Inappropriate surgical referral: Reserve surgery for grade III-IV hemorrhoids that fail less invasive approaches 1, 2
4. Inadequate fiber supplementation: Many patients don't achieve the recommended 25-30g daily intake 1
5. Prolonged use of topical steroids: Limit hydrocortisone suppositories to short-term use due to potential long-term safety concerns 1

The evidence strongly supports a stepwise approach to managing non-thrombosed hemorrhoids, starting with conservative measures and progressing to more invasive interventions only when necessary, with treatment decisions guided by hemorrhoid grade and symptom severity.