What medications are used to treat hemorrhoids?

Medications for Hemorrhoids

First-line pharmacological treatment for hemorrhoids includes increased dietary fiber (psyllium husk 5-6 teaspoonfuls with 600 mL water daily), topical analgesics (lidocaine), and short-term topical corticosteroids (≤7 days), with flavonoids as an effective adjunct for bleeding control. 1, 2

First-Line Pharmacological Options

Dietary Fiber and Bulk-Forming Agents

• Psyllium husk is the cornerstone of medical management, dosed at 5-6 teaspoonfuls with 600 mL water daily to soften stool and reduce straining 1
• Fiber supplementation prevents hemorrhoid progression and reduces bleeding episodes in all grades 3
• Osmotic laxatives (polyethylene glycol or lactulose) can be added if fiber alone is insufficient, and are safe during pregnancy 1

Topical Analgesics

• Lidocaine (5%) provides symptomatic relief of local pain and itching, though long-term efficacy data are limited 1, 2
• Topical analgesics work best when combined with other conservative measures 2

Topical Corticosteroids

• Hydrocortisone creams reduce perianal inflammation but must be limited to 7 days maximum to avoid thinning of perianal and anal mucosa 1, 2
• Hydrocortisone foam can be used safely in the third trimester of pregnancy with no adverse events 1
• Critical pitfall: Long-term use of corticosteroid suppositories is potentially harmful and should be avoided 1

Flavonoids (Phlebotonics)

• Flavonoids improve venous tone and are effective for controlling acute bleeding in all grades of hemorrhoids 2
• They reduce bleeding, rectal pain, and swelling 4
• Important limitation: Symptom recurrence reaches 80% within 3-6 months after treatment cessation 4

Second-Line Pharmacological Options

Topical Muscle Relaxants (For Thrombosed Hemorrhoids)

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks is highly effective, achieving 92% resolution rate compared to 45.8% with lidocaine alone 1, 3
• Works by relaxing internal anal sphincter hypertonicity that contributes to pain 1
• No systemic side effects observed with topical nifedipine 1
• This is superior to topical nitrates, which cause headaches in many patients 1, 2

Topical Nitrates

• Show good results for thrombosed external hemorrhoids by decreasing anal tone 2
• Major limitation: High incidence of headache may limit use 1
• Contraindicated in patients with hypotension (SBP <90 mmHg), extreme bradycardia (<50 bpm), tachycardia (>100 bpm), or those taking erectile dysfunction medications 1

Topical Heparin

• Significantly improves healing and resolution of acute hemorrhoids 1, 2
• Evidence is limited due to small study sizes 2

Treatment Algorithm Based on Hemorrhoid Type

Internal Hemorrhoids (Non-Thrombosed)

• Start with fiber supplementation (psyllium husk) plus adequate water intake 1, 2
• Add flavonoids for bleeding control 2
• Use topical analgesics (lidocaine) for discomfort 2
• Short-term topical corticosteroids (≤7 days) for inflammation 1

External Hemorrhoids (Non-Thrombosed)

• Fiber supplementation and lifestyle modifications 1
• Topical analgesics for symptomatic relief 2
• Short-term topical corticosteroids for inflammation 2

Thrombosed External Hemorrhoids

• If presenting within 72 hours: Surgical excision is preferred for faster symptom resolution 3, 4
• If presenting after 72 hours or surgery declined: Topical 0.3% nifedipine with 1.5% lidocaine every 12 hours for 2 weeks 1, 3
• Add stool softeners and oral analgesics 4
• Topical nitrates if nifedipine unavailable, but expect headache side effects 2

Essential Adjunctive Measures

• Sitz baths (warm water soaks) reduce inflammation and discomfort 1, 2
• Avoid straining during defecation 1, 2
• Adequate water intake must accompany all pharmacological treatments 2

Important Considerations and Pitfalls

What NOT to Use

• Suppository medications lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1
• Over-the-counter suppositories are widely used but clinical data supporting effectiveness are lacking 1
• Never use corticosteroid suppositories long-term due to risk of perianal tissue thinning 1

When to Escalate Treatment

• If symptoms worsen or fail to improve within 1-2 weeks, consider procedural interventions like rubber band ligation 1, 2
• Rubber band ligation achieves 89% success rates for grades I-III internal hemorrhoids 3, 4
• Surgical hemorrhoidectomy is most effective for grade III-IV hemorrhoids with 2-10% recurrence 3, 4

Red Flags Requiring Further Evaluation

• Hemorrhoids alone do not cause positive fecal occult blood tests - evaluate the colon adequately 1
• Significant bleeding, severe pain, or fever warrant immediate reassessment 1
• Anal pain suggests other pathology (anal fissure occurs in 20% of hemorrhoid patients) 1
• Anemia from hemorrhoids is rare (0.5 per 100,000 population) and should prompt colonoscopy 1