What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

For hemorrhoids treatment, rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids, with a success rate of up to 89%, while surgical hemorrhoidectomy remains the most effective treatment overall, particularly for third-degree hemorrhoids. 1

Classification and Diagnosis

• Hemorrhoids are classified as internal (above the dentate line) or external (below the dentate line), with internal hemorrhoids further graded from I to IV based on the degree of prolapse 1
• Internal hemorrhoids typically present with painless rectal bleeding during defecation, while external hemorrhoids cause acute pain when thrombosed 1, 2
• A careful anorectal evaluation is essential as symptoms from other conditions are frequently misattributed to hemorrhoids 1

Conservative Management (First-Line)

• First-line treatment for all hemorrhoid grades is conservative management with dietary and lifestyle modifications 1, 3
• Key components include:
  • Increased fiber and water intake to soften stool and reduce straining 1, 4
  • Avoidance of straining during defecation 4
  • Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Treatment

• Topical analgesics such as lidocaine provide symptomatic relief of local pain and itching 1, 5
• Topical corticosteroids may reduce local perianal inflammation but should be limited to no more than 7 days to avoid thinning of perianal and anal mucosa 1, 5
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) for thrombosed external hemorrhoids 1, 4
• Flavonoids can improve venous tone and are effective for controlling acute bleeding in all grades of hemorrhoids 5, 6

Office-Based Procedures

• Rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids 1, 2

  • Works by tightly encircling redundant tissue, causing necrosis and subsequent scarring 1
  • Success rates vary from 70.5% to 89% depending on hemorrhoid grade 1
  • The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
  • Pain is the most common complication (5-60% of patients) but is typically minor 1

• Injection sclerotherapy is suitable for first and second-degree hemorrhoids 1, 3

  • Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
  • Efficacious in the short term (70-85% of patients) but long-term remission occurs in only one-third of patients 6

• Infrared photocoagulation for first and second-degree hemorrhoids 7

  • Controls bleeding in 67-96% of patients 7
  • Complications including pain and bleeding are uncommon 7

Surgical Management

• Surgical hemorrhoidectomy is indicated for:

  • Failure of medical and non-operative therapy 1
  • Symptomatic third or fourth-degree hemorrhoids 1, 2
  • Mixed internal and external hemorrhoids 1, 6

• Conventional excisional hemorrhoidectomy:

  • Most effective treatment overall, particularly for third-degree hemorrhoids 7, 1
  • Low recurrence rate (2-10%) 1, 6
  • Associated with more pain and longer recovery (9-14 days) 1, 6

• Stapled hemorrhoidopexy:

  • Faster postoperative recovery but higher recurrence rate compared to excisional hemorrhoidectomy 2, 6
  • Particularly advisable for circular hemorrhoids 8

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours):

  • Excision under local anesthesia is recommended for faster pain relief and reduced recurrence risk 1, 6
  • Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence rates 1, 4

• For later presentation (>72 hours):

  • Conservative management is preferred, including stool softeners, oral and topical analgesics 1, 6
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks 1

Treatment Algorithm Based on Hemorrhoid Grade

• Grade I (bleeding without prolapse):

  • Conservative management with increased fiber and water intake 1, 3
  • If persistent symptoms: rubber band ligation, sclerotherapy, or infrared photocoagulation 1, 2

• Grade II (prolapse that reduces spontaneously):

  • Conservative management as first-line 1, 3
  • If persistent: rubber band ligation (preferred) or other office-based procedures 1, 2

• Grade III (prolapse requiring manual reduction):

  • Initial conservative management 1
  • Rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy 2
  • Surgical hemorrhoidectomy if office procedures fail 1, 3

• Grade IV (irreducible prolapse):

  • Excisional hemorrhoidectomy or stapled hemorrhoidopexy 2, 6

Important Considerations and Pitfalls

• 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
• 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 1, 4
• Necrotizing pelvic sepsis is a rare but serious complication of rubber band ligation, with increased risk in immunocompromised patients 7, 1
• Anal dilatation is not recommended as a treatment option due to high rates of associated incontinence 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1