What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

Rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids, while surgical hemorrhoidectomy is the most effective treatment for third and fourth-degree hemorrhoids. 1, 2

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades based on symptoms and physical findings:

  • Grade I: Bleeding without prolapse
  • Grade II: Prolapse with spontaneous reduction
  • Grade III: Prolapse requiring manual reduction
  • Grade IV: Irreducible prolapse 1, 2

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

Conservative Management (First-Line)

• Conservative management is the first-line treatment for all hemorrhoid grades and includes: 1, 3

  • Increased fiber and water intake to soften stool and reduce straining 1
  • Avoidance of straining during defecation 1, 4
  • Sitz baths for symptomatic relief 4

• Pharmacological options include:

  • Flavonoids to improve venous tone and control acute bleeding 4
  • Topical analgesics (e.g., lidocaine) for pain and itching relief 4
  • Short-term topical corticosteroids (≤7 days) to reduce inflammation 1, 4
  • Topical muscle relaxants for thrombosed or strangulated hemorrhoids 4

Office-Based Procedures

• Rubber band ligation:

  • Most effective office-based procedure with success rates of 70.5-89% 1, 2
  • Works by tightly encircling redundant tissue, causing necrosis and subsequent scarring 1
  • Must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
  • Complications include pain (5-60%), minor bleeding, and rarely necrotizing pelvic sepsis 1
  • Contraindicated in immunocompromised patients 1

• Injection sclerotherapy:

  • Suitable for first and second-degree hemorrhoids 1
  • Short-term efficacy of 70-85%, but long-term remission in only one-third of patients 2

• Infrared photocoagulation:

  • Controls bleeding in 67-96% of patients with first or second-degree hemorrhoids 5
  • Complications including pain and bleeding are uncommon 5
  • 70-80% success in reducing bleeding and prolapse 2

• Bipolar diathermy:

  • Success rates of 88-100% in randomized trials for first to third-degree hemorrhoids 5
  • Does not eliminate prolapsing tissue; up to 20% require excisional hemorrhoidectomy 5

Surgical Management

• Indications for surgical hemorrhoidectomy:

  • Hemorrhoids too extensive for non-operative management
  • Failure of non-operative management
  • Symptomatic third or fourth-degree hemorrhoids
  • Mixed internal and external hemorrhoids 5, 2

• Surgical options:

  • Conventional excisional hemorrhoidectomy (open or closed):

    • Most effective treatment with low recurrence (2-10%) 5, 2
    • Associated with more pain and longer recovery (9-14 days) 2, 6

  • Stapled hemorrhoidopexy:

    • Faster postoperative recovery but higher recurrence rate 3, 6
    • Particularly advisable for circular hemorrhoids 7

  • Hemorrhoidal artery ligation:

    • Less pain and quicker recovery, but higher recurrence rate 6, 7

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours):

  • Excision under local anesthesia provides faster pain relief and reduces risk of recurrence 1, 8
  • Simple incision and drainage alone is not recommended due to persistent bleeding and higher recurrence rates 8

• For later presentation (>72 hours):

  • Conservative management is preferred as the natural resolution process has begun 1, 8
  • Treatment includes stool softeners, oral and topical analgesics 1, 8
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) 8

Treatment Algorithm Based on Hemorrhoid Grade

• Grade I hemorrhoids:

  • Start with conservative management 1, 3
  • If persistent, consider rubber band ligation, sclerotherapy, or infrared photocoagulation 1, 3

• Grade II hemorrhoids:

  • Start with conservative management 1, 3
  • If persistent, rubber band ligation is preferred over other office-based procedures 1, 2

• Grade III hemorrhoids:

  • Start with conservative management 1
  • If persistent, rubber band ligation is first-line procedural treatment 1, 2
  • For recurrent symptoms, consider surgical hemorrhoidectomy 5, 2

• Grade IV hemorrhoids:

  • Conservative management may provide symptomatic relief 1
  • Surgical hemorrhoidectomy is the definitive treatment 5, 3

Important Considerations and Pitfalls

• Avoid long-term use of high-potency corticosteroid suppositories as they can harm anal tissue 1, 8
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 8
• Always rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids 8
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer 8
• Necrotizing pelvic sepsis is a rare but serious complication of rubber band ligation, with increased risk in immunocompromised patients 1