What is the treatment for intermittent rectal bleeding and anal pruritus (itching)?

From the Guidelines

For intermittent rectal bleeding and anal pruritus, the most effective initial treatment is to try over-the-counter hemorrhoid treatments like hydrocortisone cream (0.5-1%) applied to the anal area up to four times daily for 1-2 weeks, or witch hazel pads after bowel movements, as recommended by the most recent guidelines 1.

Initial Treatment

These symptoms commonly indicate hemorrhoids, which are swollen blood vessels in the rectal area.

• Increase fiber intake to 25-30g daily through foods like fruits, vegetables, and whole grains, or with a fiber supplement like Metamucil (1 tablespoon in water 1-3 times daily) to prevent worsening, as supported by a meta-analysis 1.
• Drink 6-8 glasses of water daily to help soften stool and reduce straining during bowel movements.
• Limit time spent sitting on the toilet to reduce pressure on the rectal area.

Medical History and Physical Examination

In patients with suspected bleeding hemorrhoids, a complete physical examination, including a digital rectal examination, is suggested to rule out other causes of lower gastrointestinal bleeding 1.

• Check vital signs, determine hemoglobin and hematocrit, and assess coagulation to evaluate the severity of the bleeding.
• In case of severe bleeding, blood typing and cross-matching are suggested.

Monitoring and Follow-up

If symptoms persist beyond two weeks, worsen, include significant pain, or if you notice larger amounts of blood, seek medical attention promptly as these could indicate other conditions requiring different treatment 1.

• People over 45 with rectal bleeding should consult a doctor regardless, as this could require further evaluation.
• The use of flavonoids, such as Daflon, may be beneficial in relieving symptoms, as suggested by a meta-analysis 1.

Important Considerations

• Long-term use of high-potency corticosteroid creams should be avoided due to potential deleterious effects 1.
• The role of topical anti-thrombotic therapy and NSAIDs is not yet clear, and more research is needed to determine their effectiveness in treating complicated hemorrhoids 1.

From the FDA Drug Label

temporarily relieves external anal and genital itching other uses of this product should only be under the advice and supervision of a doctor Stop use and ask a doctor if ... rectal bleeding occurs

The treatment for intermittent rectal bleeding is to stop use and ask a doctor. For anal pruritus (itching), hydrocortisone (TOP) can be applied to the affected area not more than 3 to 4 times daily, but rectal bleeding requires medical attention. 2 2 2

From the Research

Treatment Options for Intermittent Rectal Bleeding and Anal Pruritus

• The treatment for intermittent rectal bleeding and anal pruritus (itching) often depends on the underlying cause, with hemorrhoids being a common cause of these symptoms 3, 4, 5, 6, 7.
• For non-thrombosed hemorrhoids, nonsurgical treatment includes increased fiber intake, sitz baths, and drugs 3.
• Rubber band ligation is the most effective office-based procedure for grades I, II, and III hemorrhoids 3, 4.
• Surgical hemorrhoidectomy is indicated after failure of nonsurgical management and office-based procedures and also as initial management for grades III and IV hemorrhoids 3, 4, 6, 7.
• For acutely thrombosed external hemorrhoids, excision and evacuation of the clot, ideally within 72 hours of symptom onset, is the optimal management 3, 5.
• Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 4.
• Topical remedies may provide symptomatic relief, but evidence for this is poor 7.
• Bulk laxatives alone may improve symptoms of both bleeding and prolapse and seem as effective as injection sclerotherapy 7.

Specific Treatment Approaches

• Rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate 4.
• Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids 4, 6, 7.
• Stapled hemorrhoidopexy has a faster postoperative recovery, but a higher recurrence rate 4, 7.
• Postoperative pain from excisional hemorrhoidectomy can be treated with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics 4.
• Minimally invasive operations, such as Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation, and stapled hemorrhoidopexy, have been introduced to avoid post-hemorrhoidectomy pain 6.