What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The most effective treatment approach for hemorrhoids begins with conservative management including increased fiber and water intake for all hemorrhoid grades, with progression to office-based procedures like rubber band ligation for grades I-III, and surgical interventions for grades III-IV or refractory cases. 1, 2

Classification and Assessment

• Hemorrhoids are classified as internal (above the dentate line) or external (below the dentate line) 1
• Internal hemorrhoids are further graded I-IV based on prolapse severity: grade I (bleeding without prolapse), grade II (prolapse with spontaneous reduction), grade III (prolapse requiring manual reduction), and grade IV (irreducible prolapse) 3
• A complete physical examination including digital rectal examination and anoscopy should be performed to rule out other causes of anorectal symptoms 2
• Colonoscopy should be considered if there is concern for inflammatory bowel disease or colorectal cancer based on patient history or examination findings 2

First-Line Conservative Management

• Conservative management is recommended as first-line treatment for all hemorrhoid grades 1, 2
• Key components include:
  • Increased dietary fiber (5-6 teaspoons of psyllium husk with 600 mL water daily) 1, 2
  • Adequate water intake to soften stool and reduce straining 1
  • Proper bathroom habits to avoid prolonged straining 2
  • Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Management

• Topical treatments provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1
• Effective topical options include:
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment (applied every 12 hours for two weeks) for thrombosed hemorrhoids (92% resolution rate) 2, 4
  • Topical analgesics (e.g., lidocaine) for pain and itching relief 4
  • Short-term topical corticosteroids (≤7 days) to reduce local inflammation 1, 4
  • Flavonoids to improve venous tone and control acute bleeding 4
• Oral medications include:
  • Bulk-forming agents like psyllium husk 1
  • Flavonoids to improve venous tone, though symptom recurrence reaches 80% within 3-6 months after treatment cessation 3

Office-Based Procedures

• Rubber band ligation is the most effective office-based procedure for grades I-III internal hemorrhoids 1, 2

  • Success rates up to 89%, though repeated banding is needed in up to 20% of cases 1, 3
  • The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
  • Contraindicated in immunocompromised patients due to risk of necrotizing pelvic infection 1

• Other office-based options include:

  • Injection sclerotherapy for grades I-II hemorrhoids (70-85% short-term success) 1, 3
  • Infrared coagulation (70-80% success in reducing bleeding and prolapse) 3

Management of Thrombosed External Hemorrhoids

• For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia is preferred for faster pain relief and lower recurrence rates 1, 2
• For presentation >72 hours after onset, conservative management is recommended with:
  • Stool softeners 1
  • Oral and topical analgesics 1
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment 2, 4
• Simple incision and drainage of the thrombus alone is NOT recommended due to persistent bleeding and higher recurrence rates 1

Surgical Management

• Surgical intervention is indicated for:

  • Failure of medical and non-operative therapy 1
  • Symptomatic grade III or IV hemorrhoids 1
  • Mixed internal and external hemorrhoids 1

• Surgical options include:

  • Conventional excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson techniques) - most effective treatment with low recurrence rate (2-10%) but longer recovery (9-14 days) 1, 2, 3
  • Stapled hemorrhoidopexy - faster postoperative recovery but higher recurrence rate 5, 3
  • Hemorrhoidal artery ligation 1

Special Considerations

• Pregnancy: Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents, and hydrocortisone foam (in third trimester) 1
• Avoid anal dilatation as a treatment option 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

Treatment Algorithm Based on Hemorrhoid Type and Grade

• Internal Hemorrhoids:

  • Grade I-II: Conservative management → Rubber band ligation or sclerotherapy if conservative measures fail 1, 3
  • Grade III: Conservative management → Rubber band ligation → Surgical options if needed 1, 3
  • Grade IV: Surgical management (excisional hemorrhoidectomy or stapled hemorrhoidopexy) 5, 3

• External Hemorrhoids:

  • Asymptomatic: No specific treatment required 6
  • Thrombosed (<72 hours): Surgical excision under local anesthesia 1, 2
  • Thrombosed (>72 hours): Conservative management with topical treatments 1