What are the treatment options for hemorrhoids?

Hemorrhoid Treatment Options

Treatment of hemorrhoids should be tailored according to their severity, with conservative management as first-line therapy for most cases, progressing to office-based procedures and surgery only when necessary. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades 1:

  • First-degree: Bleed but do not protrude
  • Second-degree: Protrude with defecation but reduce spontaneously
  • Third-degree: Protrude and require manual reduction
  • Fourth-degree: Cannot be reduced

• External hemorrhoids are located below the dentate line and typically cause symptoms only when thrombosed 1, 2

Conservative Management

First-Line Treatment for All Hemorrhoids

• The cornerstone of medical therapy is adequate intake of fiber and water to soften stool and reduce straining 1
• Lifestyle modifications including avoiding straining during defecation 2
• Topical corticosteroids and analgesics for perianal skin irritation due to poor hygiene, mucus discharge, or fecal seepage 1
  • Caution: Prolonged use of potent corticosteroid preparations may be harmful and should be avoided 1
• Flavonoids (phlebotonics) may help relieve symptoms, though recurrence rates reach 80% within 3-6 months after treatment cessation 1, 2
• Topical muscle relaxants may be beneficial for thrombosed or strangulated hemorrhoids 1

Office-Based Procedures

For First to Third-Degree Hemorrhoids

• Rubber band ligation is the treatment of choice for grades 1-2 hemorrhoids and is appropriate for grade 3 when medical therapy fails 1, 3

  • Involves placing a band around the base of hemorrhoid tissue to restrict blood flow 2
  • Resolves symptoms in 89% of patients, though repeated banding is needed in up to 20% 2
  • Associated with the lowest recurrence rate among non-operative techniques 1
  • May cause more discomfort than other office procedures 1
  • Caution: Immunocompromised patients are at increased risk for severe infection 1

• Other office-based procedures include 1, 2:

  • Injection sclerotherapy (for first and second-degree hemorrhoids)
    • Efficacious in short term (70-85%) but long-term remission occurs in only one-third of patients 2
    • Higher relapse rate compared to rubber band ligation 1
  • Infrared coagulation
    • Yields 70-80% success in reducing bleeding and prolapse 2
  • Diathermy coagulation and bipolar coagulation 1

• Cryotherapy has a high complication rate and is no longer recommended 1, 4

Surgical Management

For Thrombosed External Hemorrhoids

• If diagnosed early (within 72 hours of onset), thrombosed external hemorrhoids are best managed by excision under local anesthesia in the office or clinic 1, 2
• Excision is not required for patients whose symptoms are resolving, as pain typically resolves after 7-10 days 1
• Patients presenting more than 72 hours after thrombosis should receive medical treatment (stool softeners, oral and topical analgesics) 2

For Advanced Internal Hemorrhoids

• Hemorrhoidectomy is the most effective treatment but should be reserved for specific indications due to increased pain and complications 1:

  1. Failure of medical and non-operative therapy
  2. Symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids
  3. Symptomatic hemorrhoids with concomitant anorectal condition requiring surgery
  4. Patient preference after discussion of options

• Surgical techniques include 1, 2:

  • Excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson technique)
    • Low recurrence rate (2-10%) but longer recovery (9-14 days) 2
  • Stapled hemorrhoidopexy
    • Associated with less postoperative pain than conventional hemorrhoidectomy 1
    • Faster recovery but higher recurrence rate 3
  • Doppler-guided hemorrhoidal artery ligation (HAL/RAR)
    • Better tolerated but higher recurrence rate 4

• Manual dilatation of the anus is not recommended due to risk of sphincter injury and incontinence 1, 4

• Laser hemorrhoidectomy offers no advantage over conventional techniques and is more costly 1

Special Considerations

• For acutely prolapsed, incarcerated, and thrombosed hemorrhoids, either hemorrhoidectomy or excision of the external component with rubber band ligation of the internal hemorrhoids is recommended 1

• Imaging investigations (CT scan, MRI, or endoanal ultrasound) should only be performed if there is suspicion of concomitant anorectal diseases (sepsis/abscess, inflammatory bowel disease, neoplasm) 1

• Anoscopy should be performed as part of the physical examination when feasible and well tolerated 1

• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 1