What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

Treatment of hemorrhoids should follow a stepwise approach based on hemorrhoid grade, with conservative measures as first-line therapy for all patients, progressing to office-based procedures for persistent symptoms, and reserving surgery for advanced cases or those that fail less invasive treatments. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades based on symptoms and physical findings:
  • First-degree: Bleed but do not protrude 1
  • Second-degree: Protrude with defecation but reduce spontaneously 1
  • Third-degree: Protrude and require manual reduction 1
  • Fourth-degree: Cannot be reduced 1
• External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1

Conservative Management

• First-line treatment for all hemorrhoid grades is conservative management with dietary and lifestyle modifications 1
• Key components include:
  • Increased fiber and water intake to soften stool and reduce straining 1, 2
  • Proper bathroom habits to avoid prolonged straining 1
  • Topical treatments for symptom relief:
    • Analgesics for pain and itching 1
    • Corticosteroids for perianal skin irritation (short-term use only) 1
    • Muscle relaxants for thrombosed hemorrhoids 1
  • Flavonoids (phlebotonics) to improve venous tone and reduce symptoms 1, 2, 3

Office-Based Procedures

For patients with persistent symptoms despite conservative management:

• Rubber band ligation - most effective office-based procedure:

  • Appropriate for first to third-degree hemorrhoids 1
  • Achieves symptom resolution in up to 89% of patients 2
  • Associated with the lowest recurrence rate among non-operative techniques 1, 2
  • May cause more discomfort than other office procedures 1
  • Contraindicated in immunocompromised patients due to infection risk 1

• Injection sclerotherapy:

  • Suitable for first and second-degree hemorrhoids 1
  • Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
  • High initial success rate (70-90%) but higher long-term recurrence 1, 2

• Infrared coagulation:

  • Uses heat to coagulate hemorrhoidal tissue 2
  • Effective in 70-80% of cases for reducing bleeding and prolapse 2

• Not recommended:

  • Cryotherapy (high complication rate) 1
  • Anal dilation (risk of sphincter injury) 4

Surgical Management

• Hemorrhoidectomy is indicated for:

  • Failure of medical and non-operative therapy 1
  • Symptomatic third or fourth-degree hemorrhoids 1
  • Mixed internal and external hemorrhoids 1
  • Concurrent anorectal conditions requiring surgery 1

• Surgical options include:

  • Conventional excisional hemorrhoidectomy:

    • Most effective treatment with lowest recurrence rate (2-10%) 2
    • Associated with more pain and longer recovery (9-14 days) 2
    • Ferguson (closed) technique may cause less postoperative pain than Milligan-Morgan (open) technique 4

  • Stapled hemorrhoidopexy (Longo procedure):

    • Less postoperative pain and faster recovery than conventional hemorrhoidectomy 4
    • Higher recurrence rate 4
    • Particularly suitable for circumferential hemorrhoids 4

  • Hemorrhoidal artery ligation (with or without recto-anal repair):

    • Better tolerated but higher recurrence rate than conventional hemorrhoidectomy 4

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours):

  • Excision under local anesthesia is recommended 1, 2
  • Provides faster pain relief and reduces risk of recurrence 2

• For later presentation (>72 hours):

  • Conservative management is preferred as symptoms typically resolve in 7-10 days 1
  • Treatment includes stool softeners, oral and topical analgesics 2
  • Simple incision and drainage is not recommended 1

Special Considerations

• Complicated hemorrhoids:

  • Imaging (CT, MRI, or endoanal ultrasound) only if suspicion of concomitant anorectal disease 1
  • Anoscopy recommended as part of physical examination 1
  • Colonoscopy indicated if concern for inflammatory bowel disease or cancer 1

• Acutely prolapsed, incarcerated hemorrhoids:

  • May require hemorrhoidectomy or excision of external component with rubber band ligation of internal hemorrhoids 1
  • Stapled hemorrhoidopexy may be considered in emergency situations 4