Treatment of External Hemorrhoids
For external hemorrhoids, the treatment approach should focus on conservative management first, with surgical intervention reserved for thrombosed hemorrhoids within 72 hours of symptom onset. 1, 2
Conservative Management (First-Line)
- Increase fiber and water intake to soften stool and reduce straining during defecation 1, 2
- Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1
- Avoid prolonged straining during bowel movements to prevent exacerbation of symptoms 2
- Topical analgesics can provide symptomatic relief of local pain and itching 3, 1
- Short-term topical corticosteroids (≤7 days) can reduce local perianal inflammation, but long-term use should be avoided due to potential thinning of perianal and anal mucosa 3, 1, 2
Treatment for Thrombosed External Hemorrhoids
Early Presentation (within 72 hours):
- Surgical excision under local anesthesia is recommended for faster pain relief and reduced risk of recurrence 1, 4, 2
- Simple incision and drainage of the thrombus alone is NOT recommended due to persistent bleeding and higher recurrence rates 1, 4, 2
Later Presentation (>72 hours):
- Conservative management is preferred as the natural resolution process has begun 1, 4, 2
- Pharmacological options include:
- Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks (92% resolution rate) 1, 2
- Topical nitrates can relieve pain due to thrombosed external hemorrhoids by decreasing anal tone, though headaches may limit their use 3, 1, 2
- Topical heparin treatment has shown promise in improving healing, though evidence is limited 1, 2
Important Considerations and Pitfalls
- Long-term use of high-potency corticosteroid creams is deleterious and should be avoided 3, 1
- If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1, 4, 2
- Even if hemorrhoids are seen on examination, patients with rectal bleeding who are at risk of colorectal cancer should still undergo colonoscopy to exclude cancer as the etiology 5, 6
- Thrombosed external hemorrhoids are slightly more prevalent on the left side (51%), whereas ordinary internal hemorrhoids tend to develop more on the right side (61%) 7
- The condition is usually self-limiting and subsides in a few days to a week with conservative management 7
Follow-up Recommendations
- If conservative management fails after 1-2 weeks, surgical intervention may be necessary 1, 4
- For recurrent external hemorrhoids, addressing underlying causes such as constipation and straining is essential for long-term management 6, 7
- Patients with mixed hemorrhoidal disease (concurrent internal and external hemorrhoids) may require more comprehensive treatment approaches, including excisional hemorrhoidectomy for persistent symptoms 8, 6