What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

The most effective treatment for hemorrhoids depends on their classification, with conservative management being first-line for all grades, rubber band ligation for grades I-III internal hemorrhoids, and surgical hemorrhoidectomy for grade IV or refractory cases. 1, 2

Classification and Diagnosis

• Internal hemorrhoids originate above the dentate line and are classified into four grades:

  • Grade I: Bleed but do not prolapse
  • Grade II: Prolapse and reduce spontaneously
  • Grade III: Prolapse and require manual reduction
  • Grade IV: Prolapsed and irreducible 1, 3

• External hemorrhoids develop below the dentate line and typically become symptomatic only when thrombosed, causing acute pain and a palpable perianal lump 4, 1

• A careful anorectal evaluation is essential as symptoms from other conditions (anal fissures, abscesses) are frequently attributed to hemorrhoids 4

Conservative Management (First-Line for All Hemorrhoids)

• Dietary and lifestyle modifications are the cornerstone of initial treatment for all hemorrhoid grades 1, 2:

  • Increased fiber intake (25-30g/day) and adequate water consumption to soften stool and reduce straining 1, 2
  • Bulk-forming agents like psyllium husk (5-6 teaspoons with 600mL water daily) help regulate bowel movements 1, 2
  • Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1
  • Avoiding prolonged straining during defecation 1, 2

• Topical treatments for symptomatic relief:

  • Topical analgesics for pain and itching 1
  • Short-term topical corticosteroids (≤7 days) for perianal inflammation 1, 2
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) for thrombosed hemorrhoids 2

Office-Based Procedures for Internal Hemorrhoids

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

  • Success rates of 70.5-89% depending on hemorrhoid grade 1
  • The band must be placed at least 2cm proximal to the dentate line to avoid severe pain 1
  • More effective than sclerotherapy and requires fewer additional treatments 1, 5
  • Common complications include pain (5-60% of patients) and minor bleeding 1

• Injection sclerotherapy is suitable for grades I and II hemorrhoids 1:

  • Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
  • Short-term efficacy in 70-85% of patients, but long-term remission in only one-third 3

• Infrared coagulation uses heat to coagulate hemorrhoidal tissue:

  • 70-80% success in reducing bleeding and prolapse 3
  • Less effective than rubber band ligation 5

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours):

  • Surgical excision under local anesthesia provides faster pain relief and reduces recurrence risk 1, 2
  • Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence rates 1

• For later presentation (>72 hours):

  • Conservative management is preferred 1, 6
  • Treatment includes stool softeners, oral and topical analgesics 1, 6
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment is highly effective 2

Surgical Management

• Indications for surgical intervention include:

  • Failure of conservative and office-based treatments 1
  • Symptomatic grade III or IV hemorrhoids 1, 3
  • Mixed internal and external hemorrhoids 1

• Conventional excisional hemorrhoidectomy:

  • Most effective treatment overall, particularly for third-degree hemorrhoids 1, 2
  • Low recurrence rate (2-10%) 1, 3
  • Longer recovery period (9-14 days) and more postoperative pain 3

• Stapled hemorrhoidopexy:

  • Faster postoperative recovery but higher recurrence rate compared to conventional hemorrhoidectomy 7
  • Elevates grade III or IV hemorrhoids to their normal anatomic position 5

Special Considerations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 6
• Safe treatments include:
  • Dietary fiber and adequate fluid intake 6
  • Bulk-forming agents like psyllium husk 6
  • Osmotic laxatives such as polyethylene glycol or lactulose 6
  • Hydrocortisone foam (shown to be safe in the third trimester) 6

Important Pitfalls to Avoid

• Do not attribute fecal occult blood to hemorrhoids until the colon is adequately evaluated 4
• Avoid assuming all anorectal symptoms are due to hemorrhoids, as other conditions like anal fissures may coexist 6
• Avoid long-term use of high-potency corticosteroid suppositories due to potential thinning of perianal and anal mucosa 1, 2
• 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