What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The first-line treatment for all hemorrhoid grades is conservative management with dietary and lifestyle modifications, including increased fiber and water intake to soften stool and reduce straining. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades 2, 1:

  • Grade I: Bleeding without prolapse
  • Grade II: Prolapse that reduces spontaneously
  • Grade III: Prolapse requiring manual reduction
  • Grade IV: Irreducible prolapse

• External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1

Conservative Management

• Dietary modifications are essential first-line treatments 1, 3:

  • Increased fiber intake to soften stool 1
  • Adequate hydration 1
  • Avoiding straining during defecation 1

• Topical treatments for symptom relief 1:

  • Analgesics for pain and itching 1
  • Corticosteroid creams for perianal inflammation (limited to 7 days to avoid skin thinning) 1
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is effective for thrombosed external hemorrhoids 1
  • Topical nitrates can relieve pain but may cause headaches 1

• Oral medications 2, 1:

  • Phlebotonics (flavonoids) can increase venous tone and reduce bleeding, pain, and swelling, though symptoms may recur after discontinuation 3
  • Micronized purified flavonoid fraction (MPFF) has shown symptomatic improvement in controlled trials but is not FDA-approved in the US 2, 4

Office-Based Procedures for Internal Hemorrhoids

• Rubber band ligation 2, 1:

  • Most effective office-based procedure for grades I-III hemorrhoids 1
  • Success rate of up to 89% 1
  • Bands must be placed at least 2 cm above the dentate line to avoid pain 2
  • Repeated banding may be needed in up to 20% of cases 3

• Injection sclerotherapy 2, 1:

  • Suitable for grades I-II hemorrhoids 1
  • Uses sclerosing agents (5% phenol in oil, quinine and urea, or hypertonic salt solution) 2
  • Short-term efficacy in 70-85% of patients, but long-term remission in only one-third 3
  • Complications include pain (12-70% of patients), impotence, urinary retention, and abscess 2

• Infrared coagulation 3:

  • Uses heat to coagulate hemorrhoidal tissue 3
  • 70-80% success in reducing bleeding and prolapse 3
  • Less effective than rubber band ligation 5

Surgical Management

• Hemorrhoidectomy 1, 3:

  • Indicated for failure of medical and non-operative therapy, symptomatic grade III-IV hemorrhoids, and mixed hemorrhoids 1
  • Achieves low recurrence (2-10%) but requires longer recovery (9-14 days) 3
  • Closed hemorrhoidectomy (Ferguson) appears superior to open (Milligan-Morgan) for postoperative pain and wound healing 6

• Stapled hemorrhoidopexy 1, 6:

  • Elevates grade III-IV hemorrhoids to normal position 1
  • Associated with less postoperative pain and faster recovery than conventional hemorrhoidectomy 6
  • Higher recurrence rate compared to excisional hemorrhoidectomy 6

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours) 1, 5:

  • Excision under local anesthesia provides faster pain relief and reduces recurrence risk 1

• For later presentation (>72 hours) 1:

  • Conservative management with stool softeners, oral and topical analgesics 1
  • Topical treatments as described above 1

Treatment Algorithm Based on Hemorrhoid Grade

1. All grades: Start with conservative measures (fiber, water, avoid straining) 1
2. Grades I-II: If conservative measures fail, proceed to rubber band ligation or sclerotherapy 1
3. Grade III: Try rubber band ligation first; if unsuccessful, consider hemorrhoidectomy 1, 3
4. Grade IV: Surgical management (hemorrhoidectomy or stapled hemorrhoidopexy) 1, 3
5. Thrombosed external: Excision if <72 hours; conservative management if >72 hours 1

Common Pitfalls and Caveats

• Long-term use of high-potency corticosteroid creams should be avoided due to skin thinning 2, 1
• Rubber band placement too close to the dentate line can cause severe pain 2
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and need for additional therapy 2
• Phlebotonics may provide temporary relief but have high recurrence rates after discontinuation 3
• Surgical procedures should be reserved for cases that fail conservative and office-based treatments 1, 3