Treatment of External Hemorrhoids
Initial Conservative Management (First-Line for All External Hemorrhoids)
Conservative management with dietary modifications and topical treatments is the recommended first-line approach for all external hemorrhoids, reserving surgical excision only for thrombosed external hemorrhoids presenting within 72 hours of symptom onset. 1
Dietary and Lifestyle Modifications
- Increase fiber intake (such as psyllium husk 5-6 teaspoonfuls with 600 mL water daily) and water consumption to soften stool and reduce straining during defecation 1
- Avoid straining during bowel movements, as this is crucial for preventing symptom exacerbation 1
- Regular sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1
Topical Pharmacological Treatments
For symptomatic external hemorrhoids, topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective, achieving 92% resolution compared to 45.8% with lidocaine alone. 1
- Nifedipine works by relaxing internal anal sphincter hypertonicity that contributes to pain, with no observed systemic side effects 1
- Lidocaine provides symptomatic relief of local pain and itching 1
- Short-term topical corticosteroids (≤7 days) may reduce local perianal inflammation, but must be limited to avoid thinning of perianal and anal mucosa 1
- Topical nitrates show good results for pain relief but have high incidence of headache, which may limit their use 1
- Topical heparin has shown promise in improving healing, though evidence is limited 1
Important caveat: Never use corticosteroid creams for more than 7 days due to risk of perianal tissue thinning and increased injury risk 1
Management of Thrombosed External Hemorrhoids
The treatment approach depends critically on timing of presentation:
Early Presentation (Within 72 Hours of Symptom Onset)
Surgical excision under local anesthesia is recommended for thrombosed external hemorrhoids presenting within 72 hours, as this provides faster pain relief and reduces risk of recurrence. 1
- Excision is superior to simple incision and drainage, which is NOT recommended due to persistent bleeding and higher recurrence rates 1
- This approach provides the most rapid and persistent symptom resolution 2
Late Presentation (>72 Hours After Symptom Onset)
Conservative management is preferred for thrombosed external hemorrhoids presenting after 72 hours, as the natural resolution process has typically begun. 1, 3
Conservative treatment includes:
- Stool softeners to reduce straining 1, 3
- Oral analgesics for pain control 3
- Topical analgesics such as 5% lidocaine 3
- Topical 0.3% nifedipine with 1.5% lidocaine ointment (92% resolution rate) 1
- Short-term topical corticosteroids (≤7 days maximum) 1
- Sitz baths for symptomatic relief 1
When to Escalate Care
Indications for Reassessment
- Symptoms worsen or fail to improve within 1-2 weeks of conservative treatment 1
- Significant bleeding occurs 1
- Severe pain develops 1
- Fever develops (may indicate necrotizing pelvic sepsis, a rare but serious complication) 4
Surgical Hemorrhoidectomy Indications
Surgical excision is indicated for:
- Failure of conservative and topical medical therapy 1
- Mixed internal and external hemorrhoids causing significant symptoms 3
- Recurrent thrombosis despite conservative management 1
Conventional excisional hemorrhoidectomy is the most effective treatment overall with low recurrence rates (2-10%), though it requires longer recovery (9-14 days) and is associated with more postoperative pain than conservative approaches. 1, 3
Important Clinical Pitfalls to Avoid
- Do not assume all anorectal symptoms are due to hemorrhoids - perform careful anorectal evaluation to rule out anal fissures (present in up to 20% of patients with hemorrhoids), abscesses, fistulas, or other pathology 1
- Do not perform simple incision and drainage of thrombosed external hemorrhoids - this leads to persistent bleeding and higher recurrence rates 1
- Do not use topical corticosteroids long-term - limit to 7 days maximum to prevent perianal tissue thinning 1
- Anal pain is NOT typical of uncomplicated hemorrhoids - its presence suggests other pathology such as anal fissure or thrombosis 1
- Do not attribute positive fecal occult blood tests to hemorrhoids until the colon is adequately evaluated, as hemorrhoids alone do not cause positive stool guaiac tests 1
Special Populations
Pregnancy
- Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 1
- Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
- Osmotic laxatives such as polyethylene glycol or lactulose can be used safely 1
- Hydrocortisone foam can be used safely in the third trimester with no adverse events 1
Immunocompromised Patients
- Increased risk of necrotizing pelvic infection with any invasive procedures 5
- The clinical triad of severe pain, high fever, and urinary retention suggests necrotizing pelvic sepsis requiring emergency debridement 5
- This includes patients with uncontrolled AIDS, neutropenia, and severe diabetes mellitus 5