What is the treatment for external hemorrhoids?

Treatment of External Hemorrhoids

For external hemorrhoids, the recommended treatment approach depends on whether the hemorrhoid is thrombosed and the timing of presentation, with conservative management as first-line for non-thrombosed hemorrhoids and surgical excision within 72 hours for thrombosed hemorrhoids. 1, 2, 3

Non-thrombosed External Hemorrhoids

First-line Conservative Management

• Increase dietary fiber and water intake to soften stool and reduce straining during defecation 1, 3
• Avoid prolonged straining during bowel movements 3
• Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1
• Topical analgesics for symptomatic relief of local pain and itching 4, 1

Topical Treatment Options

• Topical lidocaine preparations can provide symptomatic relief of local pain and itching 1, 3
• Short-term topical corticosteroids (≤7 days) can reduce local perianal inflammation, but should be avoided for long-term use due to potential thinning of perianal and anal mucosa 4, 1, 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours has shown high efficacy by relaxing internal anal sphincter hypertonicity 1, 3

Thrombosed External Hemorrhoids

Treatment Based on Timing of Presentation

Early Presentation (within 72 hours of symptom onset)

• Surgical excision under local anesthesia is the preferred treatment for faster pain relief and reduced risk of recurrence 2, 3, 5
• Simple incision and drainage alone is not recommended due to persistent bleeding and higher recurrence rates 2, 3

Later Presentation (>72 hours after symptom onset)

• Conservative management is preferred as the natural resolution process has begun 2, 3
• Treatment includes stool softeners, oral and topical analgesics (such as 5% lidocaine) 1, 5
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks has shown 92% resolution rate 2, 3
• Non-steroidal anti-inflammatory drugs are effective for pain and edema in external thrombosis 6

Pharmacological Options for Thrombosed Hemorrhoids

• Topical muscle relaxants can provide pain relief 2, 3
• Topical nitrates have shown good results in relieving pain, though headaches may limit their use 1, 3
• Topical heparin treatment has shown promise in improving healing, though evidence is limited 1, 3
• Flavonoids can be administered to relieve symptoms 2, 3

Important Considerations and Pitfalls

• Long-term use of high-potency corticosteroid creams is deleterious and should be avoided 4, 1, 2
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1, 2, 3
• Thrombosed external hemorrhoids are often self-limiting and may resolve spontaneously within a few days to a week 7
• Always rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids 1, 8
• Patients with rectal bleeding who are at risk of colorectal cancer (e.g., adults older than 50 years) should undergo colonoscopy to exclude cancer as the etiology 8
• Approximately 10% of patients with hemorrhoidal disease will eventually require surgical treatment 6