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 conservative management being the first-line treatment for all hemorrhoid grades. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades: first-degree (bleeding without prolapse), second-degree (prolapse with spontaneous reduction), third-degree (prolapse requiring manual reduction), and fourth-degree (irreducible prolapse) 1
• External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1

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
  • Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1
  • Avoidance of straining during defecation 1, 2
  • Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) 1

Pharmacological Treatment Options

• Topical treatments for symptom relief:
  • Analgesics (e.g., lidocaine) for pain and itching 1, 2
  • Corticosteroids for perianal inflammation (limited to ≤7 days to prevent tissue thinning) 1, 2
  • Flavonoids to improve venous tone and control bleeding 2
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment (applied every 12 hours for two weeks) for thrombosed hemorrhoids (92% resolution rate) 1, 3
  • Topical muscle relaxants for pain associated with anal sphincter hypertonicity 2

Office-Based Procedures

• Rubber band ligation:

  • Most effective office-based procedure for first to third-degree hemorrhoids 1
  • Success rates up to 89% 1
  • Performed by placing a band at least 2 cm proximal to the dentate line 4
  • Most common complication is pain (5-60% of patients) 4
  • Contraindicated in immunocompromised patients 1

• Injection sclerotherapy:

  • Suitable for first and second-degree hemorrhoids 1
  • Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
  • Improvement rates of 89.9% reported in some studies 4
  • Pain reported in 12-70% of patients 4

• Other office-based procedures:

  • Infrared photocoagulation: Controls bleeding in 67-96% of patients with first or second-degree hemorrhoids 4
  • Bipolar diathermy: Success rates of 88-100% for bleeding control 1
  • Cryotherapy: Not recommended due to prolonged pain and foul-smelling discharge 4

Surgical Management

• Indications for surgery:

  • Failure of medical and non-operative therapy 1
  • Symptomatic third or fourth-degree hemorrhoids 1
  • Mixed internal and external hemorrhoids 1

• Surgical options:

  • Conventional excisional hemorrhoidectomy: Most effective treatment overall, particularly for third-degree hemorrhoids; recurrence rate 2-10% 1, 5
  • Stapled hemorrhoidopexy: Faster recovery but higher recurrence rate compared to excisional hemorrhoidectomy 6
  • Hemorrhoidal artery ligation: Better tolerated but higher recurrence rate 7

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours):

  • Surgical excision under local anesthesia is recommended 1, 3
  • Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence rates 3

• For later presentation (>72 hours):

  • Conservative management is preferred as the natural resolution process has begun 1, 3
  • Treatment includes stool softeners, oral and topical analgesics 1, 5
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment is highly effective 3

Treatment Algorithm Based on Hemorrhoid Grade

• Grade I (bleeding without prolapse):

  • Conservative management with increased fiber and water intake 1
  • If persistent: Rubber band ligation, sclerotherapy, or infrared photocoagulation 1, 6

• Grade II (prolapse with spontaneous reduction):

  • Conservative management as first-line 1
  • If persistent: Rubber band ligation preferred over other office-based procedures 1, 6

• Grade III (prolapse requiring manual reduction):

  • Conservative management initially 1
  • Rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy 6

• Grade IV (irreducible prolapse):

  • Excisional hemorrhoidectomy or stapled hemorrhoidopexy 6, 5

Important Considerations and Pitfalls

• Avoid assuming all anorectal symptoms are due to hemorrhoids; other conditions like anal fissures, abscesses, or fistulas may coexist 1
• 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 long-term use of high-potency corticosteroid suppositories as they can potentially harm anal tissue 3
• Necrotizing pelvic sepsis is a rare but serious complication of rubber band ligation, with increased risk in immunocompromised patients 4
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 3