What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

For hemorrhoids, treatment should be tailored based on classification, with rubber band ligation being the most effective office-based procedure for first to third-degree hemorrhoids, and surgical hemorrhoidectomy reserved for advanced or complicated cases. 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, 2
• External hemorrhoids are located below the dentate line and typically become symptomatic only when thrombosed, causing acute pain 1, 3

Conservative Management (First-Line for All Grades)

• Increased dietary fiber and water intake to soften stool and reduce straining is the cornerstone of first-line treatment for all hemorrhoid grades 1, 2
• Topical treatments provide symptomatic relief:
  • Analgesics for pain and itching 1
  • Short-term corticosteroids (≤7 days) for perianal skin irritation 1, 4
  • Flavonoids can improve venous tone and control bleeding, though recurrence rates reach 80% within 3-6 months after stopping treatment 2, 4
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1

Office-Based Procedures for Internal Hemorrhoids

• Rubber band ligation is the most effective office-based procedure with success rates up to 89% 1, 2

  • Works by placing a band around hemorrhoid tissue to restrict blood flow
  • Most effective for grades I-III internal hemorrhoids
  • Bands must be placed at least 2cm proximal to dentate line to avoid severe pain 1
  • Pain occurs in 5-60% of patients but is typically minor 1
  • Contraindicated in immunocompromised patients due to risk of necrotizing pelvic infection 1

• Injection sclerotherapy for first and second-degree hemorrhoids 1

  • Short-term efficacy in 70-85% of patients, but long-term remission in only one-third 2

• Infrared photocoagulation for first and second-degree hemorrhoids 1

  • Controls bleeding in 67-96% of patients 5
  • Complications including pain and bleeding are uncommon 5

• Bipolar diathermy/cautery for first to third-degree internal hemorrhoids 5

  • Success rates for bleeding control range from 88-100% 5
  • Does not eliminate prolapsing tissue effectively 5

Surgical Management

• Surgical hemorrhoidectomy is indicated for: 1, 2

  • Failure of conservative and office-based treatments
  • Symptomatic third or fourth-degree hemorrhoids
  • Mixed internal and external hemorrhoids
  • Recurrence rates are low (2-10%) but recovery is longer (9-14 days) 2

• Stapled hemorrhoidopexy has faster recovery but higher recurrence rates compared to conventional hemorrhoidectomy 6, 7

Management of Thrombosed External Hemorrhoids

• For presentation within 72 hours: excision under local anesthesia provides faster pain relief and reduces recurrence risk 1
• For presentation after 72 hours: conservative management with stool softeners, oral and topical analgesics 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) 1, 3
• Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence rates 1

Important Considerations and Pitfalls

• Anal pain is generally not associated with uncomplicated hemorrhoids; its presence suggests other pathology such as anal fissure 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
• Anemia due to hemorrhoidal disease is rare 1
• Cryotherapy and anal dilatation are not recommended due to complications and poor outcomes 1
• Long-term use of topical corticosteroids should be avoided due to risk of thinning perianal and anal mucosa 4, 3