What is the treatment for external thrombosed hemorrhoids?

Treatment of External Thrombosed Hemorrhoids

For external thrombosed hemorrhoids, early surgical excision within 72 hours of symptom onset is recommended for fastest pain relief and reduced recurrence risk, while conservative management is preferred for presentations beyond 72 hours. 1, 2

Initial Assessment and Management

• External thrombosed hemorrhoids present with acute-onset anal pain and a palpable perianal lump, occasionally bleeding when local pressure causes erosion through the overlying skin 1
• Anoscopy should be performed as part of the physical examination when feasible and well tolerated 3
• First-line treatment for all hemorrhoids includes conservative management with dietary and lifestyle modifications:
  • Increased fiber and water intake 3, 1
  • Avoiding straining during defecation 1, 2
  • Sitz baths for symptomatic relief 1

Treatment Algorithm Based on Time of Presentation

Early Presentation (within 72 hours)

• Surgical excision under local anesthesia is recommended for faster pain relief and reduced risk of recurrence 1, 2, 4
• The procedure involves an elliptic incision over the thrombosis site with removal of the entire diseased hemorrhoidal plexus in one piece 5
• Simple incision and drainage of the thrombus is not recommended due to persistent bleeding and higher recurrence rates 1

Later Presentation (>72 hours)

• Conservative management is preferred as the natural resolution process has begun 1, 2
• Pharmacological options include:
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks (highly effective with 92% resolution rate) 1, 6
  • Flavonoids to relieve symptoms 3, 7
  • Topical muscle relaxants for pain relief 3, 7
  • Short-term topical corticosteroids (≤7 days) to reduce local inflammation 1, 7
  • Stool softeners and oral analgesics 2, 4

Pharmacological Management Details

• Topical nifedipine works by relaxing internal anal sphincter hypertonicity which contributes to pain, with no reported systemic side effects 1, 6
• Topical lidocaine provides symptomatic relief of local pain and itching 1, 7
• Topical nitrates can be considered for pain relief if other options are ineffective, though headaches may limit their use 1, 7
• Topical heparin treatment has shown promise in improving healing, though evidence is limited 1, 7
• Corticosteroid creams should be limited to short-term use (≤7 days) to avoid thinning of perianal and anal mucosa 1, 7

Important Considerations and Pitfalls

• Avoid long-term use of high-potency corticosteroid suppositories as they can potentially harm the anal tissue 1
• Be cautious during surgical excision to avoid cutting into the muscle sphincter below the hemorrhoidal vessels 5
• Prescribe stool softeners postoperatively to prevent tearing at the suture line if surgical management is chosen 5
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1
• The condition is often self-limiting and may subside in a few days to a week with conservative management 8
• Thrombosed external hemorrhoids are more common in younger patients (mean age 36 years) and often preceded by constipation 8