What is the treatment for an external thrombosed hemorrhoid?

Treatment of External Thrombosed Hemorrhoid

For external thrombosed hemorrhoids, excision under local anesthesia is recommended if presenting within 72 hours of symptom onset, while conservative management is preferred for presentations beyond 72 hours. 1

Initial Assessment and Treatment Approach

• Treatment approach depends primarily on the timing of presentation since symptom onset 1, 2:
  • Early presentation (<72 hours): Surgical excision provides faster pain relief and reduces recurrence risk
  • Later presentation (>72 hours): Conservative management is preferred as the natural resolution process has begun

Conservative Management (For presentations >72 hours)

• Conservative treatment includes the following measures:

  • Increased fiber and water intake to soften stool and reduce straining 1, 3
  • Stool softeners to prevent exacerbation of symptoms 1, 4
  • Sitz baths for symptomatic relief 3
  • Avoidance of straining during defecation 1, 3

• Topical treatments for symptom relief:

  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective for pain relief 1
  • Topical analgesics (lidocaine) provide symptomatic relief of local pain and itching 1, 3
  • Short-term topical corticosteroids (≤7 days) can reduce local perianal inflammation 1, 3
  • Topical nitrates can relieve pain but may cause headaches 1, 3
  • Topical heparin may improve healing, though evidence is limited 1, 3

Surgical Management (For presentations <72 hours)

• Complete surgical excision under local anesthesia is recommended for presentations within 72 hours 1, 5

• The procedure involves:

  • Elliptical incision over the site of thrombosis 5
  • Removal of the entire diseased hemorrhoidal plexus in one piece 5
  • Caution to avoid cutting into the underlying sphincter muscle 5

• Post-surgical care:

  • Stool softeners to prevent tearing at the suture line 5
  • Oral analgesics for pain management 1, 2

Important Considerations and Pitfalls

• Simple incision and drainage of the thrombus (without excision) is not recommended due to persistent bleeding and higher recurrence rates 1
• Long-term use of high-potency corticosteroid creams/suppositories should be avoided due to potential thinning of perianal and anal mucosa 1, 3
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1
• External hemorrhoids are more common in males (2:1 ratio) with a mean age of 36 years 4
• Constipation often precedes the development of thrombosed external hemorrhoids, making stool softening a key preventive measure 4

Follow-up Recommendations

• For patients managed conservatively, symptoms typically resolve within a few days to a week 4
• If conservative treatment fails, surgical excision should be considered 4, 6
• Preventive measures should be emphasized to reduce recurrence risk:
  • Maintaining adequate fiber and fluid intake 1, 3
  • Avoiding prolonged straining during defecation 1, 3