What are the management options for hemorrhoids (piles)?

Management of Hemorrhoids (Piles)

Non-operative management with dietary and lifestyle changes is the recommended first-line therapy for all types of hemorrhoids, including increased fiber and water intake along with proper bathroom habits.1, 2

Initial Assessment and Classification

• Hemorrhoids are classified as internal (originating above the dentate line) or external (arising below the dentate line)2, 3
• Internal hemorrhoids are graded from I to IV based on the extent of prolapse:
  • Grade I: Bleeding without prolapse
  • Grade II: Prolapse with spontaneous reduction
  • Grade III: Prolapse requiring manual reduction
  • Grade IV: Irreducible prolapse2, 3, 4
• For suspected bleeding hemorrhoids, perform a complete physical examination including digital rectal examination to rule out other causes of lower gastrointestinal bleeding1
• Check vital signs, hemoglobin, hematocrit, and coagulation parameters to evaluate bleeding severity1
• Anoscopy should be performed as part of the physical examination when feasible and well tolerated1
• Imaging investigations (CT, MRI, or endoanal ultrasound) are only indicated if there is suspicion of concomitant anorectal diseases such as abscess, inflammatory bowel disease, or neoplasm1

Conservative Management

• First-line treatment for all hemorrhoid grades includes:
  • Increased fiber and water intake to soften stool and reduce straining1, 2
  • Proper bathroom habits to avoid prolonged straining2, 5
  • Sitz baths for symptomatic relief6, 3
• Dietary fiber supplementation (5-6 teaspoonfuls of psyllium husk with 600 mL water daily) can prevent progression of hemorrhoids and reduce bleeding episodes2, 5
• The "TONE" approach is recommended:
  • T: Three minutes at defecation
  • O: Once-a-day defecation frequency
  • N: No straining during bowel movements
  • E: Enough fiber2, 5

Pharmacological Management

• Flavonoids are recommended to relieve hemorrhoidal symptoms by improving venous tone and controlling acute bleeding2, 6, 3
• For thrombosed or strangulated hemorrhoids, topical muscle relaxants are suggested for pain relief1, 6, 7
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) for thrombosed hemorrhoids2, 7
• Topical analgesics like lidocaine provide symptomatic relief of local pain and itching2, 6
• Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa2, 6, 7
• Avoid long-term use of high-potency corticosteroid suppositories as they can potentially harm anal tissue2, 7

Office-Based Procedures

• Rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids, with success rates of up to 89%2, 3, 4
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain2
• Injection sclerotherapy is suitable for first and second-degree hemorrhoids, with short-term efficacy in 70-85% of patients2, 4
• Infrared coagulation yields 70-80% success in reducing bleeding and prolapse3, 4

Management of Thrombosed External Hemorrhoids

• For thrombosed hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia is preferred for faster symptom resolution and lower recurrence rates2, 7, 3
• Simple incision and drainage of the thrombus alone is not recommended due to persistent bleeding and higher recurrence rates1, 7
• For presentation more than 72 hours after symptom onset, conservative management is preferred as the natural resolution process has begun2, 7
• Conservative management includes stool softeners, oral and topical analgesics, and topical muscle relaxants2, 7, 3

Surgical Management

• Surgical intervention is indicated for:
  • Failure of medical and non-operative therapy
  • Symptomatic third or fourth-degree hemorrhoids
  • Mixed internal and external hemorrhoids2, 3, 4
• Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for third-degree hemorrhoids, with a low recurrence rate of 2-10%2, 3, 4
• Other surgical options include stapled hemorrhoidopexy and hemorrhoidal artery ligation2, 3, 8

Important Considerations and Pitfalls

• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended2, 7
• Always rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids2
• Hemorrhoids alone do not cause positive stool guaiac tests, so fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated2
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination1, 7
• Anal dilatation is not recommended as a treatment option due to high rates of associated incontinence2