Treatment of Thrombosed Hemorrhoids
For thrombosed hemorrhoids, surgical excision under local anesthesia is recommended within 72 hours of symptom onset for fastest pain relief and reduced recurrence risk. After 72 hours, conservative management with topical treatments is preferred as the natural resolution process has begun. 1, 2
Initial Assessment
- Thrombosed external hemorrhoids present with acute-onset anal pain and a palpable perianal lump, occasionally bleeding when local pressure causes erosion through the overlying skin 2
- Anoscopy should be performed as part of the physical examination when feasible and well tolerated 2
- Imaging investigations (CT scan, MRI, or endoanal ultrasound) are only indicated if there is suspicion of concomitant anorectal diseases like sepsis/abscess, inflammatory bowel disease, or neoplasm 3
Treatment Algorithm Based on Timing
Early Presentation (within 72 hours)
- Surgical excision under local anesthesia is the preferred treatment, providing faster symptom resolution and lower recurrence rates 1, 2, 4
- The procedure is performed through an elliptic incision over the site of thrombosis with removal of the entire diseased hemorrhoidal plexus in one piece 4
- Simple incision and drainage of the thrombus alone is not recommended due to persistent bleeding and higher recurrence rates 3, 2
Later Presentation (>72 hours)
- Conservative management is preferred as the natural resolution process has begun 1, 2
- First-line therapy includes dietary and lifestyle changes (increased fiber and water intake) to soften stool and reduce straining 3, 1, 2
- Sitz baths can provide symptomatic relief 2
Pharmacological Management
- Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) 1, 2
- Flavonoids can be administered to relieve symptoms 3, 2
- Topical muscle relaxants are suggested for pain relief 3, 2
- Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa 1, 2
- Topical lidocaine provides symptomatic relief of local pain and itching 1, 2
- Stool softeners must be prescribed postoperatively to help prevent tearing at the suture line if surgical management is chosen 4
Important Considerations and Pitfalls
- Avoid long-term use of high-potency corticosteroid suppositories as they can potentially harm the anal tissue 1, 2
- If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1, 2
- When performing surgical excision, caution must be exercised to avoid cutting into the muscle sphincter below the hemorrhoidal vessels 4
- Infection after suture closure is rare due to the rich vascular network in the anal area 4
- Always rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids 5
- Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 3, 5