From the Guidelines
External thrombosed hemorrhoids are best treated with surgical excision under local anesthesia, as it provides immediate pain relief and prevents recurrence of the same clot. This procedure is recommended based on the most recent and highest quality study available, which suggests that early surgical excision can result in more rapid symptom resolution, lower incidence of recurrence, and longer remission intervals 1. The decision between non-operative management and early surgical excision should be based on local expertise and patient’s preference, as stated in the guidelines 1.
Some of the key points to consider when treating external thrombosed hemorrhoids include:
- Surgical excision under local anesthesia is the most effective treatment, providing immediate pain relief and preventing recurrence of the same clot
- Incision and drainage is not recommended due to the higher incidence of bleeding and relapse of symptoms 1
- Conservative management with warm sitz baths, over-the-counter pain relievers, and topical treatments can help manage symptoms while waiting for spontaneous resolution, which typically occurs within 1-2 weeks
- Minimally invasive procedures like rubber band ligation, infrared coagulation, and sclerotherapy may be considered for some patients, but the evidence is limited
- Early treatment (within 72 hours of onset) typically yields better results as the clot is easier to remove before it hardens
It's worth noting that the evidence on the treatment of external thrombosed hemorrhoids is limited, and more research is needed to determine the best course of treatment for each individual patient. However, based on the available evidence, surgical excision under local anesthesia is the recommended treatment for external thrombosed hemorrhoids, as it provides the best outcomes in terms of pain relief, recurrence, and quality of life 1.
From the Research
Types of Procedures to Treat External Thrombosed Hemorrhoids
- Surgical removal of the thrombosed external hemorrhoid, which can be performed through an elliptic incision over the site of thrombosis with removal of the entire diseased hemorrhoidal plexus in one piece 2
- Excision of thrombosed external hemorrhoids, which can greatly reduce pain if performed within the first two to three days of symptoms 3
- Incision and evacuation of the thrombus, which can provide immediate pain relief but may be associated with a higher rate of recurrences and bleeding 4
- Hemorrhoidectomy, which can be performed using various techniques, including conventional excisional hemorrhoidectomy, Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation, and stapled hemorrhoidopexy 5
- Conservative management, which may include medical treatment with stool softeners, topical over-the-counter preparations, and topical nitroglycerine, as well as dietary modifications and behavioral therapies such as sitz baths 3, 6
Considerations for Treatment
- The optimal treatment for external thrombosed hemorrhoids is unclear, and the choice of treatment may depend on various factors, including the severity of symptoms, the patient's overall health, and their preferences 6
- Surgical treatment may be superior to conservative treatment, but there is no evidence regarding the optimal period of initiation of conservative management 6
- Elderly patients may prefer medical treatment or immediate incision of thrombus due to fear of complications, but surgical treatment can be safe and effective in this population 4