What medications can be prescribed for hemorrhoids?

Medication Options for Hemorrhoids

For hemorrhoids, first-line treatment includes topical medications such as corticosteroids (for short-term use ≤7 days), topical analgesics, and flavonoids, along with conservative measures like increased fiber and water intake. 1, 2

Classification of Hemorrhoids

• Internal hemorrhoids originate above the dentate line and are classified into four grades based on severity of prolapse 2
• External hemorrhoids arise below the dentate line and typically cause symptoms only when thrombosed 2
• Mixed hemorrhoids involve both internal and external components 3

First-Line Medication Options

Topical Treatments

• Short-term topical corticosteroids (≤7 days) effectively reduce local inflammation but prolonged use should be avoided due to risk of perianal skin thinning 1, 2
• Topical analgesics (e.g., lidocaine) provide symptomatic relief for pain and itching 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective for thrombosed external hemorrhoids by relaxing internal anal sphincter hypertonicity 2
• Topical heparin has shown significant improvement in healing and resolution of acute hemorrhoids 2

Oral Medications

• Flavonoids (phlebotonics) can be administered to relieve hemorrhoidal symptoms by improving venous tone 1, 3
• Phlebotonics reduce bleeding, rectal pain, and swelling, though symptoms may recur within 3-6 months after stopping treatment 3

Management Based on Hemorrhoid Type

For Internal Hemorrhoids

• Conservative management with dietary fiber, adequate hydration, and topical treatments is first-line therapy 1, 2, 4
• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements 5, 6
• If conservative measures fail, office-based procedures like rubber band ligation should be considered 1, 2

For External Hemorrhoids

• Topical analgesics and short-term corticosteroids provide symptomatic relief 2
• For thrombosed external hemorrhoids:
  • Within 72 hours of onset: excision under local anesthesia is recommended 2, 4
  • After 72 hours: conservative management with stool softeners, oral and topical analgesics 2, 3

For Thrombosed or Strangulated Hemorrhoids

• Topical muscle relaxants are recommended 1, 4
• Topical nifedipine with lidocaine is particularly effective 2
• Avoid incision and drainage as it leads to persistent bleeding and higher recurrence rates 1, 4

Special Considerations

Pregnancy-Related Hemorrhoids

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 5
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 5
• Osmotic laxatives such as polyethylene glycol or lactulose can be used safely during pregnancy 5
• In a prospective study of 204 patients, hydrocortisone foam was used safely for hemorrhoids in the third trimester with no adverse events compared to placebo 5

Common Pitfalls to Avoid

• Long-term use of potent corticosteroid preparations should be avoided due to risk of perianal skin thinning 1, 2
• Incision and drainage of thrombosed hemorrhoids is not recommended 1, 4
• Assuming all anorectal symptoms are due to hemorrhoids without ruling out other conditions 2
• Failing to consider colonoscopy for patients with rectal bleeding who are at risk for colorectal cancer (e.g., adults older than 50 years) 7

When to Consider Referral

• When conservative management fails despite adequate trial 1
• For symptomatic third-degree, fourth-degree, or mixed hemorrhoids 1
• For recurrent thrombosis or persistent symptoms despite conservative management 1
• When hemorrhoids are accompanied by concomitant anorectal conditions requiring surgery 1