What are the treatment options for hemorrhoids?

Hemorrhoid Treatment Options

For hemorrhoids, treatment should be based on the grade and symptoms, with rubber band ligation being the most effective office-based procedure for grades I-III, while surgical hemorrhoidectomy is recommended for grade IV or persistent cases. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades based on symptoms and physical findings:

  • Grade I: Bleeding without prolapse
  • Grade II: Prolapse that spontaneously reduces
  • Grade III: Prolapse requiring manual reduction
  • Grade IV: Irreducible prolapse 1, 2

• External hemorrhoids arise below the dentate line and typically cause symptoms only when thrombosed, resulting in acute pain 1, 2

Conservative Management (First-Line for All Grades)

• Increased fiber and water intake to soften stool and reduce straining is the cornerstone of first-line treatment for all hemorrhoid grades 1, 2

• Sitz baths (warm water soaks) help reduce inflammation and discomfort 1

• Topical treatments for symptom relief:

  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks (92% resolution rate) 1
  • Short-term topical corticosteroids (≤7 days) to reduce local inflammation (avoid longer use due to tissue thinning) 1
  • Over-the-counter analgesics for pain management 1, 3

Office-Based Procedures (For Grades I-III)

• Rubber band ligation is the most effective office-based procedure with success rates of 70.5-89%:

  • Works by tightly encircling redundant tissue, causing necrosis and subsequent scarring 1
  • 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 1
  • Pain occurs in 5-60% of patients but is typically minor and manageable 1, 4

• Injection sclerotherapy for first and second-degree hemorrhoids:

  • Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
  • Short-term efficacy in 70-85% of patients, but long-term remission in only one-third 2
  • Complications include pain (12-70%), impotence, urinary retention, and abscess formation 4

• Infrared photocoagulation for first and second-degree hemorrhoids:

  • Success rates of 67-96% for controlling bleeding 1
  • Multiple treatments (2-6 hemorrhoids) can be done at one time 5
  • Complications including pain and bleeding are uncommon 5

Surgical Management

• Conventional excisional hemorrhoidectomy:

  • Most effective treatment overall, particularly for third-degree hemorrhoids 1
  • Low recurrence rate of 2-10% 1, 2
  • Indicated for failure of medical and non-operative therapy, symptomatic third or fourth-degree hemorrhoids, and mixed hemorrhoids 1
  • Associated with longer recovery (9-14 days) and more postoperative pain 2

• Stapled hemorrhoidopexy:

  • Faster postoperative recovery but higher recurrence rate than excisional hemorrhoidectomy 2
  • Particularly advisable for circular hemorrhoids 6

• Hemorrhoidal artery ligation:

  • Better tolerated but higher recurrence rate than conventional surgery 6

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours):

  • Excision under local anesthesia is recommended for faster pain relief and reduced risk of recurrence 1, 2
  • Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence rates 1

• For later presentation (>72 hours):

  • Conservative management with stool softeners, oral and topical analgesics 1, 2
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment shows 92% resolution rate 1

Treatment Algorithm Based on Hemorrhoid Grade

• Grade I hemorrhoids:

  • Start with conservative management
  • If symptoms persist: infrared photocoagulation or sclerotherapy
  • If other methods fail: rubber band ligation 7

• Grade II hemorrhoids:

  • Start with conservative management
  • If symptoms persist: rubber band ligation as the preferred office-based procedure 7

• Grade III hemorrhoids:

  • Start with conservative management
  • If symptoms persist: rubber band ligation
  • If office procedures fail: surgical hemorrhoidectomy 7

• Grade IV hemorrhoids:

  • Surgical hemorrhoidectomy is typically required 7, 3

Complications and Important Considerations

• Pain is the most common complication of hemorrhoid treatment, particularly after rubber band ligation 4

• Necrotizing pelvic sepsis is a rare but serious complication of rubber band ligation, with increased risk in immunocompromised patients (including those with uncontrolled AIDS, neutropenia, and severe diabetes mellitus) 1

• Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis, requiring emergency intervention 4

• 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, occurring in approximately 0.5 patients/100,000 population 1