What are the treatment options for hemorrhoids?

Treatment of Hemorrhoids

First-Line Conservative Management for All Grades

All patients with hemorrhoids should begin with dietary and lifestyle modifications, including increased fiber (5-6 teaspoonfuls of psyllium husk with 600 mL water daily) and adequate water intake to soften stool and reduce straining. 1, 2

• Avoid prolonged straining during defecation, which exacerbates symptoms 1
• Regular sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1
• Bulk-forming agents like psyllium husk help regulate bowel movements and prevent progression 1, 3
• Flavonoids improve venous tone and control acute bleeding in all hemorrhoid grades 2

Topical Pharmacological Treatment

For Symptomatic Relief

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) for thrombosed external hemorrhoids 1, 3
• Lidocaine alone provides symptomatic relief of local pain and itching, though long-term efficacy data are limited 1, 2
• Short-term topical corticosteroids (≤7 days maximum) reduce perianal inflammation but must be limited to avoid thinning of perianal and anal mucosa 1, 2, 3

Alternative Topical Options

• Topical nitrates relieve pain from thrombosed hemorrhoids by decreasing anal tone, but headaches limit their use in many patients 1, 2
• Topical heparin significantly improves healing of acute hemorrhoids, though evidence is limited 1, 2

Critical Pitfall: Never use corticosteroid creams for more than 7 days due to risk of tissue thinning and increased injury risk 1, 2

Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure for grade I-III internal hemorrhoids, with success rates up to 89%. 1, 3, 4

• Performed in office without anesthesia by placing bands at least 2 cm proximal to the dentate line to avoid severe pain 1
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners limit to 1-2 columns 1
• Pain is the most common complication (5-60% of patients) but typically manageable with sitz baths and over-the-counter analgesics 1
• Repeated banding needed in up to 20% of patients 4

Contraindication: Avoid in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1

Alternative Office Procedures

• Injection sclerotherapy suitable for grade I-II hemorrhoids, causing fibrosis and tissue shrinkage with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 4
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids 1, 4

Surgical Management

Indications for Surgery

Surgery is indicated for: 1, 3

• Failure of medical and non-operative therapy
• Symptomatic grade III-IV hemorrhoids
• Mixed internal and external hemorrhoids
• Complications (thrombosis, strangulation)

Surgical Options

Conventional excisional hemorrhoidectomy (Milligan-Morgan or Ferguson techniques) is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with the lowest recurrence rate of 2-10%. 1, 3, 4

• Longer recovery time (9-14 days) but superior long-term outcomes 4
• Postoperative pain manageable with NSAIDs, narcotics, fiber supplements, and topical antispasmodics 5
• Stapled hemorrhoidopexy offers faster recovery but higher recurrence rates 1, 5

Procedures to Avoid:

• Anal dilatation not recommended due to 52% incontinence rate at 17-year follow-up 1
• Cryotherapy rarely used due to prolonged pain, foul-smelling discharge, and need for additional therapy 1

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

Surgical excision under local anesthesia is recommended for thrombosed external hemorrhoids presenting within 72 hours, providing faster pain relief and reduced recurrence risk. 1, 3, 4

• Simple incision and drainage NOT recommended due to persistent bleeding and higher recurrence 1, 3

Late Presentation (>72 Hours)

Conservative management preferred when pain is improving: 1, 3, 4

• Stool softeners
• Oral and topical analgesics (5% lidocaine)
• Topical 0.3% nifedipine with 1.5% lidocaine ointment (92% resolution rate) 1, 3
• Short-term corticosteroid creams (≤7 days) 1, 3

Special Populations

Pregnancy

Hemorrhoids occur in approximately 80% of pregnant persons, especially third trimester: 1

• Safe treatments include dietary fiber, adequate fluids, and psyllium husk
• Osmotic laxatives (polyethylene glycol or lactulose) safe during pregnancy
• Hydrocortisone foam safe in third trimester with no adverse events

Important Diagnostic Considerations

Critical Pitfall: Do not attribute all anorectal symptoms to hemorrhoids without proper evaluation 1, 3

• Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood requires colon evaluation 1
• Anal pain generally NOT associated with uncomplicated hemorrhoids; suggests other pathology like anal fissure (occurs in 20% of hemorrhoid patients) 1
• Anemia from hemorrhoids is rare (0.5 per 100,000 population) 1
• Perform anoscopy when feasible to assess internal hemorrhoids 1, 3
• Consider colonoscopy if concern for inflammatory bowel disease or cancer 1, 3

When to Escalate Care

Reassessment necessary if: 1, 3

• Symptoms worsen or fail to improve within 1-2 weeks
• Significant bleeding occurs
• Severe pain or fever develops