Management of Hemorrhoids
Start with conservative management for all hemorrhoid grades using increased dietary fiber (5-6 teaspoonfuls of psyllium husk with 600 mL water daily), adequate hydration, and avoidance of straining during defecation, then escalate to rubber band ligation for persistent grade I-III internal hemorrhoids, and reserve surgical hemorrhoidectomy for grade III-IV disease that fails conservative measures or for mixed/complicated hemorrhoids. 1, 2
Initial Assessment and Classification
Before initiating treatment, perform a focused evaluation:
- Digital rectal examination and anoscopy when feasible to confirm diagnosis and rule out other pathology 1, 2
- Check vital signs, hemoglobin, hematocrit, and coagulation parameters if significant bleeding is present 2
- Important caveat: Hemorrhoids alone do not cause positive fecal occult blood tests—always evaluate the colon adequately before attributing bleeding to hemorrhoids 1
- Red flag: Anal pain is generally NOT associated with uncomplicated hemorrhoids; its presence suggests other pathology like anal fissure (occurs in up to 20% of hemorrhoid patients) 1
- Consider colonoscopy if there is concern for inflammatory bowel disease or cancer based on history or examination 1, 2
Internal hemorrhoids are graded I-IV based on prolapse severity, while external hemorrhoids typically only cause symptoms when thrombosed 1.
First-Line Conservative Management (All Grades)
This is mandatory initial treatment regardless of hemorrhoid grade:
Dietary and Lifestyle Modifications
- Fiber supplementation: 5-6 teaspoonfuls of psyllium husk with 600 mL water daily to produce soft, bulky stools 1, 2, 3
- Adequate fluid intake to soften stool and reduce straining 1, 2
- Avoid prolonged straining during defecation—aim for 3 minutes maximum at defecation, once-daily bowel movements 1, 3
- Sitz baths (warm water soaks) to reduce inflammation and discomfort 1
Pharmacological Adjuncts for Symptom Relief
- Flavonoids (phlebotonics) improve venous tone and control bleeding in all grades, though symptom recurrence reaches 80% within 3-6 months after cessation 4, 5
- Topical analgesics (lidocaine) for local pain and itching relief, though long-term efficacy data are limited 1, 4
- Topical corticosteroids for perianal inflammation, but limit to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2, 4
Critical pitfall: Over-the-counter suppositories lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion—they provide only symptomatic relief 1.
Management of Thrombosed External Hemorrhoids
The timing of presentation dictates management:
Early Presentation (Within 72 Hours)
- Surgical excision under local anesthesia provides fastest pain relief and reduces recurrence risk 1, 2, 5
- Do NOT perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1, 2
Late Presentation (>72 Hours)
- Conservative management with stool softeners, oral and topical analgesics (5% lidocaine) 1, 5
- Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks shows 92% resolution rate (versus 45.8% with lidocaine alone) by relaxing internal anal sphincter hypertonicity without systemic side effects 1, 2, 4
- Alternative: Topical nitrates show good results but high incidence of headache may limit use 1, 4
Office-Based Procedures for Grade I-III Internal Hemorrhoids
When conservative management fails after 1-2 weeks:
Rubber Band Ligation (First-Line Procedural Treatment)
- Most effective office-based procedure with success rates of 70.5-89% depending on grade 1, 2, 5
- Technique: Band placed at least 2 cm proximal to dentate line to avoid severe pain; up to 3 hemorrhoids can be banded per session (though many limit to 1-2 columns) 1
- More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1
- Complications: Pain (5-60%, usually minor), abscess, urinary retention, band slippage, bleeding when eschar sloughs (1-2 weeks post-treatment) 1
- Contraindication: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic sepsis 1
Alternative Office Procedures
- Injection sclerotherapy: Suitable for grade I-II hemorrhoids using sclerosing agents to cause fibrosis; 70-85% short-term efficacy but only one-third achieve long-term remission 1, 5
- Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids; 70-80% success in reducing bleeding and prolapse 1, 5
- Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1
Surgical Management
Indications for Surgery
- Failure of medical and non-operative therapy 1
- Symptomatic grade III or IV hemorrhoids 1, 5
- Mixed internal and external hemorrhoids 1, 5
- Acutely thrombosed or strangulated hemorrhoids 1
Surgical Options
- Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique): Most effective treatment overall with 2-10% recurrence rate, particularly for grade III-IV hemorrhoids 1, 2, 5
- Recovery time: 9-14 days 5
- Stapled hemorrhoidopexy: Associated with reduced postoperative pain, shorter operation time and hospital stay, faster recovery, but higher recurrence rate compared to excisional hemorrhoidectomy 6
- Hemorrhoidal artery ligation (HAL/RAR): Similar trend toward better tolerance but higher recurrence rate 6
Obsolete/Not Recommended Procedures
- Anal dilation: NOT recommended due to 52% incontinence rate at 17-year follow-up 1
- Cryotherapy: Rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
Special Populations
Pregnancy
- Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in third trimester 1
- Safe treatments: Dietary fiber, adequate fluid intake, psyllium husk, osmotic laxatives (polyethylene glycol or lactulose) 1
- Hydrocortisone foam can be used safely in third trimester with no adverse events 1