Hemorrhoid Treatment Guidelines
Non-operative management is the first-line therapy for hemorrhoids, with dietary and lifestyle changes including increased fiber and water intake along with adequate bathroom habits. 1, 2
Classification of Hemorrhoids
- Internal hemorrhoids are classified into four grades: first-degree (bleeding without prolapse), second-degree (prolapse with spontaneous reduction), third-degree (prolapse requiring manual reduction), and fourth-degree (irreducible prolapse) 2, 3
- External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 2
Diagnostic Approach
- For patients with suspected hemorrhoids, a focused medical history and complete physical examination including digital rectal examination is recommended to rule out other causes of lower gastrointestinal bleeding 1
- Anoscopy should be performed as part of the physical examination when feasible and well tolerated 1
- Colonoscopy should be performed only if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 1
- Imaging investigations (CT scan, MRI, or endoanal ultrasound) are only recommended if there is suspicion of concomitant anorectal diseases such as abscess, inflammatory bowel disease, or neoplasm 1
Treatment Algorithm
First-Line Treatment: Conservative Management
- Non-operative management is strongly recommended as first-line therapy for all hemorrhoid grades 1, 2
- Key components include:
- Dietary modifications: increased fiber and water intake 1, 4
- Lifestyle changes: proper bathroom habits using the "TONE" approach (Three minutes at defecation, Once-a-day defecation frequency, No straining, Enough fiber) 4
- Flavonoids (phlebotonics) to relieve symptoms 1, 3
- For thrombosed or strangulated hemorrhoids, topical muscle relaxants are recommended 1
Second-Line Treatment: Office-Based Procedures
- For persistent symptomatic first to third-degree hemorrhoids despite conservative management, office-based procedures should be considered 2, 3
- Rubber band ligation is the most effective office-based procedure with success rates up to 89% 2, 5
- Other options include:
Third-Line Treatment: Surgical Management
- Surgery should be considered when non-operative approaches have failed or complications have occurred 6
- For thrombosed hemorrhoids, the decision between non-operative management and early surgical excision should be based on local expertise and patient preference 1
- Early presentation of thrombosed external hemorrhoids (within 72 hours) may benefit from excision under local anesthesia 2, 3
- Later presentation (>72 hours) is better managed conservatively with stool softeners and analgesics 2, 3
- Incision and drainage of thrombosed hemorrhoids is not recommended 1
Special Considerations
- For bleeding hemorrhoids, assessment of vital signs, hemoglobin, hematocrit, and coagulation is recommended to evaluate bleeding severity 1
- In case of severe bleeding, blood typing and cross-matching should be performed 1
- Excisional hemorrhoidectomy has the lowest recurrence rate (2-10%) but longer recovery time (9-14 days) 3
- Studies show that adequate fiber supplementation combined with proper defecation habits can prevent surgery in up to 87% of patients with advanced hemorrhoids 4
Common Pitfalls to Avoid
- Treating asymptomatic hemorrhoids: therapy is only indicated when hemorrhoids cause symptoms 5
- Performing incision and drainage of thrombosed hemorrhoids instead of complete excision or conservative management 1
- Neglecting dietary and lifestyle modifications before attempting procedural interventions 2, 7
- Failing to rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids 1