What is the mainstay of treatment for painful, non-bleeding hemorrhoids?

From the Guidelines

The mainstay of treatment for painful, non-bleeding hemorrhoids is non-operative management as first-line therapy, with dietary and lifestyle changes, including increased fiber and water intake, as well as adequate bathroom habits. This approach is supported by the most recent and highest quality study, which provides a strong recommendation based on moderate quality evidence [ 1 ]. The key components of this treatment include:

• Increasing dietary fiber to 25-30 grams daily
• Drinking 6-8 glasses of water daily
• Practicing adequate bathroom habits, such as avoiding straining during bowel movements
• Considering the use of stool softeners like docusate sodium (100mg twice daily) to help soften stool and reduce straining

Additionally, flavonoids may be suggested to relieve symptoms, as indicated by a weak recommendation based on moderate quality evidence [ 1 ]. However, the use of other pharmacological agents, such as NSAIDs, topical steroids, or injection of local anesthetics, is not recommended due to a lack of evidence supporting their effectiveness [ 1 ].

It is essential to note that these conservative approaches aim to reduce inflammation, improve blood flow to the area, and decrease pressure on the hemorrhoidal vessels, allowing them to shrink and symptoms to resolve. If symptoms persist beyond 1-2 weeks despite these measures, medical evaluation is recommended as more invasive treatments may be necessary.

From the Research

Treatment of Painful, Non-Bleeding Hemorrhoids

• The mainstay of treatment for painful, non-bleeding hemorrhoids is not explicitly stated in the provided studies, but it can be inferred that the treatment approach depends on the type and severity of the hemorrhoids.
• For external hemorrhoids, which are more likely to be painful, treatment options include:
  • Conservative management with stool softeners, analgesics, rest, warm soaks, and ice packs 2
  • Excision and evacuation of the clot for acutely thrombosed external hemorrhoids, ideally within 72 hours of symptom onset 2
• For internal hemorrhoids, which are typically painless but can become painful if prolapsed or strangulated, treatment options include:
  • Rubber band ligation, which is effective for grades I, II, and III hemorrhoids 3, 2
  • Surgical hemorrhoidectomy, which is indicated for grades III and IV hemorrhoids or after failure of non-surgical management and office-based procedures 3, 2, 4, 5
• Minimally invasive operations, such as Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation, and stapled hemorrhoidopexy, have been introduced to reduce post-operative pain and complications 4, 5

Non-Surgical Treatment Options

• Non-surgical treatment options for hemorrhoids include:
  • Increased fiber intake, sitz baths, and drugs 2
  • Topical preparations, such as stool softeners and local therapy to relieve swelling and symptoms 3
  • Bulk laxatives, which may improve symptoms of both bleeding and prolapse 5

Surgical Treatment Options

• Surgical treatment options for hemorrhoids include:
  • Excisional hemorrhoidectomy, which remains the mainstay operation for advanced hemorrhoids and complicated hemorrhoids 4, 5
  • Stapled hemorrhoidopexy, which has a faster post-operative recovery but a higher recurrence rate 3, 5
  • Minimally invasive operations, such as Ligasure hemorrhoidectomy and doppler-guided hemorrhoidal artery ligation 4, 5