What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The most effective treatment for hemorrhoids depends on their classification, with conservative management being first-line for all grades, rubber band ligation being the preferred office-based procedure for grades I-III, and surgical hemorrhoidectomy being most effective for advanced cases. 1, 2

Classification and Diagnosis

• Internal hemorrhoids are classified into four grades: first-degree (bleeding without prolapse), second-degree (prolapse with spontaneous reduction), third-degree (prolapse requiring manual reduction), and fourth-degree (irreducible prolapse) 1
• External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1
• Anoscopy should be performed when feasible and well-tolerated to properly assess internal hemorrhoids 2

Conservative Management (First-Line for All Hemorrhoids)

• Increased fiber and water intake to soften stool and reduce straining is the cornerstone of initial management for all hemorrhoid grades 1, 2
• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements and prevent progression 1, 2
• Proper bathroom habits to avoid prolonged straining are essential 2
• Sitz baths can provide symptomatic relief 3

Pharmacological Options

• Topical analgesics (e.g., lidocaine) provide symptomatic relief for pain and itching 1, 3
• Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa 1, 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) for thrombosed hemorrhoids 2
• Flavonoids can improve venous tone and control acute bleeding in all grades of hemorrhoids 3

Office-Based Procedures

Rubber Band Ligation (Preferred for Grades I-III)

• Most effective office-based procedure with success rates of 70.5-89% 1
• 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
• Up to 3 hemorrhoids can be banded in a single session 1
• Complications include pain (5-60%), abscess, urinary retention, band slippage, and rarely, necrotizing pelvic sepsis 4, 1

Other Office Procedures

• Injection sclerotherapy: Suitable for first and second-degree hemorrhoids, uses sclerosing agents to cause fibrosis 1
• Infrared photocoagulation: Controls bleeding in 67-96% of patients with first or second-degree hemorrhoids 4
• Bipolar diathermy: Success rates for bleeding control of 88-100% in patients with Grade II internal hemorrhoids 1

Surgical Management

• Indicated for failure of medical and non-operative therapy, symptomatic third or fourth-degree hemorrhoids, and mixed hemorrhoids 1
• Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for third-degree hemorrhoids, with a low recurrence rate of 2-10% 1, 2
• Other options include stapled hemorrhoidopexy and hemorrhoidal artery ligation 1
• Anal dilatation is not recommended due to high rates of associated incontinence (52% at 17-year follow-up) 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours), excision under local anesthesia provides faster pain relief and reduces recurrence risk 1, 2
• For later presentation (>72 hours), conservative management is preferred, including stool softeners, oral and topical analgesics 1, 2
• Simple incision and drainage of the thrombus is not recommended due to persistent bleeding and higher recurrence rates 2

Special Considerations

• Immunocompromised patients (including those with uncontrolled AIDS, neutropenia, and severe diabetes mellitus) have increased risk of necrotizing pelvic infection with rubber band ligation 4, 1
• Pregnant patients can safely use dietary fiber, adequate fluid intake, bulk-forming agents, osmotic laxatives, and hydrocortisone foam for hemorrhoid management 1
• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 2