Outpatient Management for Hemorrhoids
First-line treatment for all hemorrhoid grades is conservative management with dietary and lifestyle modifications, including increased fiber and water intake to soften stool and reduce straining. 1
Classification and Diagnosis
- Internal hemorrhoids are classified into four grades:
- Grade I: Bleeding without prolapse
- Grade II: Prolapse with spontaneous reduction
- Grade III: Prolapse requiring manual reduction
- Grade IV: Irreducible prolapse 1
- External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1
- Always rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids 2
Conservative Management (First-Line)
Dietary and Lifestyle Modifications
- Increase dietary fiber and water intake to soften stool and reduce straining 1
- Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements 1, 3
- Avoid straining during defecation to prevent exacerbation of symptoms 1
- The "TONE" approach can be effective:
- T: Three minutes at defecation
- O: Once-a-day defecation frequency
- N: No straining during passing motions
- E: Enough fiber 3
Topical Treatments
- Topical analgesics for pain and itching relief 1
- Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective for symptom relief 1, 2
- Short-term topical corticosteroids (≤7 days) can reduce local perianal inflammation 1, 2
- Avoid long-term use of high-potency corticosteroid preparations as they can potentially harm anal tissue 1, 2
- Flavonoids can be administered to relieve symptoms 2
Sitz Baths
- Regular warm water soaks (sitz baths) can reduce inflammation and discomfort 1
Office-Based Procedures for Persistent Symptoms
Rubber Band Ligation
- Most effective office-based procedure for first to third-degree hemorrhoids, with success rates of 70.5% to 89% 1
- The band 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, though many practitioners prefer to limit treatment to 1-2 columns at a time 1
- Contraindicated in immunocompromised patients due to increased risk of necrotizing pelvic infection 1
Injection Sclerotherapy
- Suitable for first and second-degree hemorrhoids 1
- Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
- Efficacious in the short term (weeks to months) among 70% to 85% of patients, but long-term remission occurs in only one-third of patients 4
Other Office Procedures
- Infrared coagulation uses heat to coagulate hemorrhoidal tissue, yielding 70% to 80% success in reducing bleeding and prolapse 4
- Bipolar diathermy has success rates for bleeding control of 88-100% in patients with Grade II internal hemorrhoids 1
Management of Thrombosed External Hemorrhoids
Based on Timing
- For early presentation (within 72 hours): Surgical excision under local anesthesia provides faster pain relief and reduces risk of recurrence 1, 2
- For later presentation (>72 hours): Conservative management is preferred as the natural resolution process has begun 1, 2
- Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence rates 1, 2
Conservative Approach for Thrombosed Hemorrhoids
- Stool softeners, oral and topical analgesics 1
- Topical 0.3% nifedipine with 1.5% lidocaine ointment (92% resolution rate) 2
- Short-term topical corticosteroids (≤7 days) 2
- If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 2
Surgical Management
- Indicated for:
- Failure of medical and non-operative therapy
- Symptomatic third or fourth-degree hemorrhoids
- Mixed internal and external 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, 4
- Stapled hemorrhoidopexy has a faster postoperative recovery but higher recurrence rate 4
- 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
Special Considerations
Pregnancy
- Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 1
- Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents 1
- Osmotic laxatives such as polyethylene glycol or lactulose can be used safely 1
- Hydrocortisone foam can be used safely in the third trimester 1