What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

For hemorrhoid management, rubber band ligation is the most effective office-based procedure for grades I-III internal hemorrhoids, while surgical hemorrhoidectomy is recommended for grade IV hemorrhoids or when other treatments fail. 1

Conservative Management (First-Line for All Grades)

• Conservative measures should be the initial approach for all hemorrhoid grades, including:

  • Increased dietary fiber and water intake to soften stool and reduce straining 1, 2
  • Sitz baths (warm water soaks) to reduce inflammation and discomfort 2
  • Over-the-counter analgesics for pain management 3, 1
  • Topical treatments for symptomatic relief 1, 2

• Topical treatment options include:

  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks (92% resolution rate) 1, 2
  • Short-term topical corticosteroids (≤7 days) to reduce local inflammation 1, 4
  • Flavonoids to improve venous tone and control acute bleeding 2, 4

Office-Based Procedures for Grades I-III

• Rubber band ligation is preferred for grades I-III internal hemorrhoids with:

  • Success rates of 70.5-89% depending on hemorrhoid grade 1, 2
  • The band must be placed at least 2cm proximal to the dentate line to avoid severe pain 1, 2
  • Pain occurs in 5-60% of patients but is typically minor and manageable 1

• Alternative office-based procedures include:

  • Infrared photocoagulation: 67-96% success rate for first or second-degree hemorrhoids 3, 1
  • Injection sclerotherapy: suitable for first and second-degree hemorrhoids 2, 5
  • Bipolar diathermy: 88-100% success rates for bleeding control in first to third-degree hemorrhoids 3, 2

Surgical Management for Advanced Cases

• Surgical hemorrhoidectomy is indicated for:

  • Failed office-based procedures 1, 2
  • Symptomatic third or fourth-degree hemorrhoids 1, 5
  • Mixed internal and external hemorrhoids 1, 2

• Surgical options include:

  • Conventional excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson techniques): most effective treatment for third-degree hemorrhoids with low recurrence rate of 2-10% 3, 1
  • Stapled hemorrhoidopexy: causes less pain with quicker recovery but higher recurrence rate 1, 5
  • Hemorrhoidal artery ligation: alternative with less postoperative pain 2, 6

Management of Thrombosed External Hemorrhoids

• For early presentation (within 72 hours):

  • Excision under local anesthesia provides faster pain relief and reduces recurrence risk 2
  • Simple incision and drainage alone is NOT recommended due to persistent bleeding and higher recurrence rates 2

• For later presentation (>72 hours):

  • Conservative management with stool softeners, oral and topical analgesics 2
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks 2

Treatment Algorithm Based on Hemorrhoid Grade

• Grade I hemorrhoids:

  • Conservative management first 1
  • If symptoms persist: infrared photocoagulation or sclerotherapy 1
  • If other methods fail: rubber band ligation 1

• Grade II hemorrhoids:

  • Conservative management first 1, 7
  • Rubber band ligation as the preferred office-based procedure if symptoms persist 1, 7

• Grade III hemorrhoids:

  • Conservative management initially 1
  • Rubber band ligation if symptoms persist 1, 7
  • Surgical hemorrhoidectomy if office procedures fail 1, 7

• Grade IV hemorrhoids:

  • Surgical hemorrhoidectomy is typically required 1, 5
  • Conventional excisional hemorrhoidectomy offers the lowest recurrence rate 1, 2

Complications and Considerations

• Pain is the most common complication, particularly after rubber band ligation 1
• Other potential complications include abscess formation, urinary retention, band slippage, bleeding, and rarely, necrotizing pelvic sepsis 3, 1
• Contraindications for rubber band ligation include immunocompromised patients, uncontrolled AIDS, neutropenia, or severe diabetes mellitus 3, 1
• Anal dilatation is not recommended due to high rates of associated incontinence (52% at 17-year follow-up) 2
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 2, 6