What medications are used to treat hemorrhoids?

Medications for Hemorrhoids

First-line medical treatment for hemorrhoids includes increased dietary fiber and water intake, with topical analgesics (lidocaine) for symptom relief and short-term topical corticosteroids (≤7 days) for inflammation, while flavonoids (phlebotonics) are recommended for controlling acute bleeding in all grades of hemorrhoids. 1, 2, 3

Conservative Medical Management (First-Line for All Grades)

Dietary and Lifestyle Modifications

• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) should be prescribed to soften stool and reduce straining. 1
• Osmotic laxatives such as polyethylene glycol or lactulose can be used as alternatives, particularly safe during pregnancy. 1
• Increased fiber and water intake forms the foundation of all hemorrhoid treatment and should accompany any pharmacological therapy. 1, 3

Systemic Medications

Flavonoids (Phlebotonics)

• Flavonoids are the most effective systemic medication for controlling acute bleeding in all grades of hemorrhoids by improving venous tone. 3, 4
• Micronised purified flavonoid fraction (MPFF) is specifically recommended for acute bleeding control and can be used while awaiting definitive procedural treatment. 5
• Important caveat: Symptom recurrence reaches 80% within 3-6 months after treatment cessation, so these are not curative. 4

Topical Medications

For Symptomatic Relief (All Hemorrhoid Types)

Topical Analgesics

• Lidocaine (typically 1.5% or 5%) provides symptomatic relief of local pain and itching, though long-term efficacy data are limited. 1, 3
• Can be applied as needed for symptom control. 1

Topical Corticosteroids

• Corticosteroid creams reduce local perianal inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa. 1, 2, 3
• Hydrocortisone foam can be used safely during pregnancy (third trimester) with no adverse events. 1
• Critical warning: Long-term use of high-potency corticosteroid suppositories is potentially harmful and should be avoided. 1

For Thrombosed External Hemorrhoids (Specific Regimen)

Topical Nifedipine with Lidocaine (Most Effective)

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone. 1, 2
• Works by relaxing internal anal sphincter hypertonicity that contributes to pain, with no systemic side effects observed. 1, 2
• This is the preferred topical treatment for thrombosed external hemorrhoids presenting >72 hours after onset. 2

Alternative Topical Options for Thrombosed Hemorrhoids

• Topical nitrates show good results for pain relief but high incidence of headache (up to 30-40%) may limit use. 1, 3
• Topical heparin significantly improves healing and resolution, though evidence is limited to small studies. 1, 3

Medication Algorithm Based on Hemorrhoid Type and Presentation

Internal Hemorrhoids (Grades I-III)

1. Start with bulk-forming agents (psyllium) + flavonoids for bleeding control. 1, 3
2. Add topical lidocaine for discomfort as needed. 3
3. If symptoms persist despite 1-2 weeks of medical therapy, proceed to office-based procedures (rubber band ligation). 1

External Hemorrhoids (Non-Thrombosed)

1. Dietary fiber and water intake with avoidance of straining. 1
2. Topical analgesics (lidocaine) for symptomatic relief. 3
3. External hemorrhoids typically require treatment only when thrombosed. 1

Thrombosed External Hemorrhoids

Timing determines treatment approach:

• Within 72 hours of onset: Surgical excision is preferred for faster pain relief and reduced recurrence. 2
• Beyond 72 hours: Medical management with topical 0.3% nifedipine + 1.5% lidocaine every 12 hours for 2 weeks. 2
• Add stool softeners, sitz baths, and oral analgesics as adjuncts. 1, 2
• Short-term topical corticosteroids (≤7 days) can reduce inflammation. 2

Important Limitations and Pitfalls

Suppository Medications

• Suppositories provide only symptomatic relief with no strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion. 1
• Over-the-counter topical agents are widely used empirically but lack robust clinical data supporting effectiveness. 1

When to Escalate Beyond Medical Management

• If symptoms worsen or fail to improve within 1-2 weeks, reassessment and consideration of procedural interventions is necessary. 1, 2
• Rubber band ligation achieves 70.5-89% success rates for grades I-III internal hemorrhoids. 1
• Surgical hemorrhoidectomy is most effective for grade III-IV hemorrhoids with 2-10% recurrence but requires 9-14 days recovery. 1, 4

Critical Diagnostic Considerations

• Hemorrhoids alone do not cause positive fecal occult blood tests; colon evaluation is required before attributing bleeding to hemorrhoids. 1
• Anal pain is generally not associated with uncomplicated hemorrhoids and 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

Special Populations

Pregnancy

• Safe options include dietary fiber, bulk-forming agents (psyllium), osmotic laxatives (polyethylene glycol, lactulose), and hydrocortisone foam in third trimester. 1
• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly during third trimester. 1