What is the treatment for Hemmorrhoid (Hemorrhoid) disease?

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 psyllium husk with 600 mL water daily) and adequate water intake to soften stool and reduce straining during defecation. 1, 2

• Avoid straining during bowel movements, as this is critical to preventing symptom progression 1, 3
• Regular sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1, 4
• Phlebotonics (flavonoids) can reduce bleeding, rectal pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after stopping treatment 2

Topical Treatments for Symptom 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, compared to 45.8% with lidocaine alone 1, 3
• Lidocaine provides symptomatic relief of local pain and itching 1, 3
• Short-term topical corticosteroids (≤7 days maximum) can reduce local perianal inflammation, but must never exceed 7 days to avoid thinning of perianal and anal mucosa 1, 3
• Topical nitrates show good results for pain relief but high incidence of headache may limit their use 1, 3

Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails. 5, 1, 2

Rubber Band Ligation (Preferred Office Procedure)

• Success rates range from 70.5% to 89% depending on hemorrhoid grade 1, 2
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 5, 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer 1-2 columns at a time 1
• Pain occurs in 5-60% of patients but is typically manageable with sitz baths and over-the-counter analgesics 1, 4
• Repeated banding is needed in up to 20% of patients 2
• Contraindicated in immunocompromised patients (including uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1, 4

Alternative Office Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids with 70-85% short-term efficacy, but long-term remission occurs in only one-third of patients 1, 2
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 5, 1
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 5, 1

Surgical Management for Grade III-IV Hemorrhoids

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and when concomitant conditions (fissure, fistula) require surgery. 5, 1

Conventional Excisional Hemorrhoidectomy

• Most effective treatment overall with low recurrence rates (2-10%), particularly for grade III-IV hemorrhoids 5, 1, 2
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques with no significant difference in outcomes 5
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 5
• Recovery time is 9-14 days 2

Complications of Surgical Hemorrhoidectomy

• Urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%) 5, 4
• Metronidazole, topical sphincter relaxants, and operative technique modifications can reduce postoperative pain 5

Procedures to Avoid

• Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 5, 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater 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 risk of recurrence. 1, 3, 2

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

Late Presentation (>72 Hours)

Conservative management is preferred when presentation is beyond 72 hours, as the natural resolution process has begun. 1, 3, 2

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1, 3
• Stool softeners, oral and topical analgesics (5% lidocaine) 3, 2
• Flavonoids for symptom relief 3
• Short-term topical corticosteroids (≤7 days) 3

Treatment Algorithm by Hemorrhoid Grade

Grade I (Bleeding, No Prolapse)

• Conservative management first 1, 2
• If persistent: rubber band ligation, sclerotherapy, or infrared photocoagulation 5, 1

Grade II (Prolapse with Spontaneous Reduction)

• Conservative management first 1, 2
• If persistent: rubber band ligation (preferred) 5, 1

Grade III (Prolapse Requiring Manual Reduction)

• Conservative management first 1, 2
• If persistent: rubber band ligation or surgical hemorrhoidectomy 5, 1

Grade IV (Irreducible Prolapse)

• Surgical hemorrhoidectomy 1, 2

Important Considerations and Pitfalls

• Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Anal pain is generally not associated with uncomplicated hemorrhoids; its presence suggests other pathology such as anal fissure, which occurs in up to 20% of patients with hemorrhoids 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) 1
• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1, 3
• The clinical triad of severe pain, high fever, and urinary retention after banding suggests necrotizing pelvic sepsis requiring emergency intervention 4

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in third trimester 1
• Surgical intervention should be reserved for highly selected and urgent cases 6

Immunocompromised Patients

• Increased risk of necrotizing pelvic infection after rubber band ligation 1, 4
• Conservative treatment is advocated, though surgical procedures can be safely proposed in most HIV-positive patients when indicated 6

Inflammatory Bowel Disease (Especially Crohn's Disease)

• Surgical treatment can be unsafe; severe complications like abscesses and fistulas with pelvic and retroperitoneal sepsis can occur 6
• Conservative medical approach associated with treatment of primary disease is first-line 6

Portal Hypertension and Cirrhosis

• Conservative treatment is recommended 6
• Bleeding hemorrhoids can be treated with hemorrhoidectomy only when they do not respond to other treatments 6