What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

Rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids, with success rates up to 89%, and should be the initial procedure of choice for symptomatic hemorrhoids not responding to conservative management. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades based on symptoms and physical findings, with first-degree hemorrhoids bleeding but not protruding 1
• External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1
• Mixed hemorrhoids involve both internal and external components 2

First-Line Treatment: Conservative Management

• Conservative management is recommended as first-line therapy for all hemorrhoid grades 1
• Key components include:
  • Increased dietary fiber and water intake to soften stool and reduce straining 1
  • Avoidance of straining during defecation 1, 3
  • Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1
• Pharmacological options include:
  • Flavonoids to improve venous tone and control acute bleeding 4
  • Topical analgesics like lidocaine for pain and itching relief 4
  • Short-term topical corticosteroids (≤7 days) for perianal inflammation 4
  • Topical muscle relaxants for thrombosed or strangulated hemorrhoids 4

Office-Based Procedures for Persistent Symptoms

Rubber Band Ligation

• Most effective office-based procedure with success rates of 70.5-89% 1
• Recommended for first, second, and third-degree hemorrhoids 1
• Works by causing tissue necrosis and subsequent scarring that fixes connective tissue to the rectal wall 1
• Must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• More effective than sclerotherapy and requires fewer additional treatments than other non-surgical options 1
• Pain occurs in 5-60% of patients but is typically minor and manageable with sitz baths and over-the-counter analgesics 1

Other Office-Based Options

• Injection sclerotherapy: Suitable for first and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage 1
• Infrared photocoagulation: Controls bleeding in 67-96% of patients with first or second-degree hemorrhoids 5
• Bipolar diathermy: Success rates of 88-100% for controlling bleeding in first to third-degree hemorrhoids 5

Surgical Management

• Surgical hemorrhoidectomy is indicated for:
  • Failure of medical and non-operative therapy 1
  • Symptomatic third or fourth-degree hemorrhoids 1
  • Mixed internal and external hemorrhoids 1
• Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for third-degree hemorrhoids, with low recurrence rates (2-10%) 1, 2
• Stapled hemorrhoidopexy offers faster recovery but higher recurrence rates compared to excisional hemorrhoidectomy 6, 7
• Hemorrhoidal artery ligation may be useful for grade II or III hemorrhoids with less pain and quicker recovery 7

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours): Excision under local anesthesia provides faster pain relief and reduces recurrence risk 1
• For later presentation (>72 hours): Conservative management is preferred, including stool softeners, oral and topical analgesics 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours can be effective 1, 3

Important Considerations and Pitfalls

• Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Avoid assuming all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures, abscesses, or fistulas may coexist 1
• Up to 20% of patients with hemorrhoids have concomitant anal fissures 3
• Long-term use of topical corticosteroids can cause thinning of perianal and anal mucosa 1, 3
• Cryotherapy and anal dilatation are not recommended due to complications including prolonged pain, foul-smelling discharge, and high rates of incontinence 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