What are the treatment options for haemorrhoids (hemorrhoids)?

Treatment Options for Haemorrhoids

The most effective treatment for haemorrhoids depends on their grade, with conservative management as first-line for all grades, rubber band ligation for grades 1-3, and surgical hemorrhoidectomy for grade 4 or refractory cases. 1

Classification and Diagnosis

• 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 occur below the dentate line and typically cause symptoms only when thrombosed, resulting in acute pain 1
• Mixed hemorrhoids involve both internal and external components 2
• A careful anorectal evaluation is essential as symptoms from other conditions (anal fissures, abscesses) are frequently misattributed to hemorrhoids 3

Conservative Management (First-Line for All Grades)

• Dietary and lifestyle modifications are the cornerstone of initial treatment for all hemorrhoid grades 1
• Key components include:
  • Increased fiber intake (aim for 30g/day) and adequate water consumption to soften stool and reduce straining 1, 4
  • Bulk-forming agents like psyllium husk (5-6 teaspoons with 600mL water daily) help regulate bowel movements 1, 4
  • Avoiding prolonged toilet sitting and straining during defecation 4
• Topical treatments for symptomatic relief:
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) 1, 4
  • Short-term topical corticosteroids (≤7 days) can reduce local inflammation but should be limited to avoid thinning of perianal and anal mucosa 1, 4
  • Topical analgesics can provide relief for pain and itching 1

Office-Based Procedures (For Grades 1-3)

• Rubber band ligation is the most effective office-based procedure with success rates up to 89% 1, 2
  • The band must be placed at least 2cm proximal to the dentate line to avoid severe pain 1
  • Up to 3 hemorrhoids can be banded in a single session, though many practitioners limit treatment to 1-2 columns at a time 1
  • Contraindicated in immunocompromised patients due to risk of necrotizing pelvic infection 1
• Injection sclerotherapy is suitable for first and second-degree hemorrhoids 1
  • Success rates range from 70-85% short-term, but long-term remission occurs in only one-third of patients 2
• Infrared coagulation yields 70-80% success in reducing bleeding and prolapse 2

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours), excision under local anesthesia provides faster pain relief and reduces recurrence risk 1, 4
• For later presentation (>72 hours), conservative management is preferred 1, 4
  • Treatment includes stool softeners, oral and topical analgesics 1
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment shows a 92% resolution rate compared to 45.8% with lidocaine alone 4
• Simple incision and drainage of the thrombus alone is NOT recommended due to persistent bleeding and higher recurrence rates 4

Surgical Management (For Grades 3-4 or Refractory Cases)

• Surgical intervention is indicated when conservative and office-based approaches have failed or for symptomatic third or fourth-degree hemorrhoids 1
• Conventional excisional hemorrhoidectomy is the most effective treatment overall with low recurrence rates (2-10%) 1, 2
  • Postoperative recovery typically takes 9-14 days 2
• Stapled hemorrhoidopexy has a faster postoperative recovery but higher recurrence rate compared to excisional hemorrhoidectomy 5
• Hemorrhoidal artery ligation is another surgical option 6
• 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

Hemorrhoids in Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 7
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 7
• Osmotic laxatives such as polyethylene glycol or lactulose can be used safely during pregnancy 7
• Hydrocortisone foam has been shown to be safe in the third trimester with no adverse events compared to placebo 7

Prevention of Recurrence

• Maintaining high-fiber diet and adequate hydration is essential for preventing recurrence 4
• Moderate cardio exercise (walking, swimming, cycling) for 20-45 minutes, 3-5 times weekly helps prevent recurrence 1
• Avoiding straining during defecation is crucial for prevention 1, 4

Important Pitfalls to Avoid

• Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 3, 4
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) 3
• Anal pain is generally not associated with uncomplicated hemorrhoids; its presence suggests other pathology such as anal fissure, which occurs in up to 20% of patients with hemorrhoids 3
• Long-term use of high-potency corticosteroid suppositories is potentially harmful and should be avoided 1