From the Guidelines
If a thrombosed hemorrhoid continues to grow after clotting, you should seek medical attention promptly, as the decision between non-operative management and early surgical excision should be based on local expertise and patient’s preference 1. While waiting for medical care, you can take over-the-counter pain relievers like acetaminophen (Tylenol) 500-1000mg every 6 hours or ibuprofen (Advil) 400-600mg every 6-8 hours with food for pain management. Some key points to consider in management include:
- Apply warm sitz baths for 15-20 minutes, 2-3 times daily to reduce swelling and discomfort
- Avoid straining during bowel movements
- Maintain adequate hydration
- Increase fiber intake to soften stool A growing thrombosed hemorrhoid may require medical intervention such as surgical excision, especially if it's causing severe pain or has been present for more than 72 hours. Surgical excision can be beneficial in selected patients, and the use of incision and drainage of the thrombus is not recommended due to higher incidence of bleeding and relapse of symptoms 1. Continued growth could indicate infection, additional clot formation, or other complications that need professional evaluation. Normal thrombosed hemorrhoids typically begin to shrink within a few days as the body reabsorbs the clot, so ongoing enlargement is concerning and warrants medical assessment. In patients with complicated hemorrhoids, non-operative management as first line therapy, with dietary and lifestyle changes, is recommended 1. Additionally, flavonoids may be administered to relieve symptoms, and topical muscle relaxants may be used in patients with thrombosed or strangulated hemorrhoids 1.
From the Research
Management of Thrombosed External Hemorrhoid
- The management of a thrombosed external hemorrhoid that continues to enlarge after clot formation can be either conservative or surgical, depending on the duration of symptoms and the patient's response to initial treatment 2.
- Conservative treatment options include wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection, and topical application of 0.2% glyceryl trinitrate 2.
- Surgical treatment options, such as drainage with radial incision, conventional excision, excision under local anesthesia, and stapled technique, are recommended when the thrombosed external hemorrhoid fails to respond to conservative management or when symptoms onset falls within the last 48-72 hours 2.
- Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 3.
Factors Influencing Treatment Choice
- The choice of treatment for a thrombosed external hemorrhoid depends on various factors, including the duration of symptoms, the size of the hemorrhoid, and the patient's overall health status 3, 2.
- Patient preferences, such as a prompt return to work or minimal post-operative pain, should also be taken into account when deciding on a treatment plan 4.
Current Practice and Research Gaps
- There is currently no consensus on the best approach to managing thrombosed external hemorrhoids, and more research is needed to establish evidence-based guidelines 2, 4.
- A survey of surgical practice in Australia and New Zealand found that there are areas of consensus in the management of hemorrhoids, but also many areas of community equipoise that would benefit from further research 4.