What medications can be given to treat hemorrhoids (piles)?

Medications for Hemorrhoids (Piles)

First-line medical treatment for hemorrhoids includes increased dietary fiber and water intake, combined with flavonoids for symptom control, topical analgesics like lidocaine for pain relief, and short-term topical corticosteroids (≤7 days) for inflammation. 1, 2

Conservative Medical Management (First-Line for All Grades)

Dietary and Lifestyle Modifications

• Increase dietary fiber intake (such as psyllium husk 5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining during defecation 1
• Increase water intake to maintain soft, bulky stools and prevent constipation 1, 2
• Avoid straining during defecation to prevent exacerbation of symptoms 1, 2
• Sitz baths (warm water soaks) can reduce inflammation and provide symptomatic relief 1

Oral Medications

Flavonoids (Phlebotonics)

• Flavonoids are the most effective oral medication for controlling acute bleeding in all grades of hemorrhoids by improving venous tone 2, 3
• Effective for reducing bleeding, rectal pain, and swelling 3
• Major limitation: symptom recurrence reaches 80% within 3-6 months after treatment cessation 3
• Should be used as adjunctive therapy alongside dietary modifications 2

Stool Softeners

• Recommended for thrombosed external hemorrhoids presenting >72 hours after onset 3
• Help prevent straining and reduce pressure on hemorrhoidal tissue 1

Topical Medications

For Internal Hemorrhoids

Topical Analgesics

• Lidocaine (5%) provides symptomatic relief of local pain and itching 2, 4, 3
• Data supporting long-term efficacy are limited 2
• Can be used as needed for symptom control 1

Topical Corticosteroids

• Use for no more than 7 days to ameliorate local perianal inflammation 1, 2, 4
• Critical warning: Long-term use causes thinning of perianal and anal mucosa 1, 2, 4
• Hydrocortisone foam can be used safely during pregnancy (third trimester) 1
• Avoid high-potency corticosteroid suppositories long-term due to potential harm 1, 4

For External and Thrombosed Hemorrhoids

Topical Nifedipine with Lidocaine (Most Effective)

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective with 92% resolution rate for thrombosed external hemorrhoids 1, 4
• Compared to 45.8% resolution with lidocaine alone 1
• Works by relaxing internal anal sphincter hypertonicity which contributes to pain 1
• No systemic side effects observed with topical nifedipine application 1

Topical Nitrates (Second-Line)

• Topical nitroglycerin shows good results for thrombosed external hemorrhoids by decreasing anal tone 1, 2
• Major limitation: High incidence of headache may limit use 1, 2
• Contraindications: Hypotension (SBP <90 mmHg), extreme bradycardia (<50 bpm), tachycardia (>100 bpm), or concurrent use of erectile dysfunction medications (sildenafil, tadalafil, vardenafil) 1

Topical Heparin

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

Suppositories

Important caveat: Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

• Topical analgesics in suppository form can provide symptomatic relief of local pain and itching 1
• Clinical data supporting effectiveness of over-the-counter suppositories are lacking 1
• Avoid long-term use of high-potency corticosteroid suppositories as they are potentially harmful 1, 4

Treatment Algorithm Based on Hemorrhoid Type and Timing

Grade I-III Internal Hemorrhoids

1. Start with: Dietary fiber + water intake + flavonoids 1, 2
2. Add if needed: Topical lidocaine for pain/itching 2
3. Add if inflamed: Topical corticosteroids for ≤7 days only 2
4. If persistent after 1-2 weeks: Consider rubber band ligation 1, 4

External Hemorrhoids (Non-Thrombosed)

1. Start with: Dietary fiber + water intake 1
2. Add: Topical lidocaine for discomfort 2
3. Add if inflamed: Short-term topical corticosteroids (≤7 days) 2

Thrombosed External Hemorrhoids

Within 72 Hours of Onset

• Surgical excision under local anesthesia is preferred for faster symptom resolution and lower recurrence rates 1, 4
• Medical management can be offered if patient declines surgery 4

After 72 Hours of Onset

1. Start with: Stool softeners + dietary modifications 4, 3
2. Add: Topical 0.3% nifedipine with 1.5% lidocaine every 12 hours for 2 weeks 1, 4
3. Add: Flavonoids for symptom relief 4
4. Add if needed: Oral analgesics (over-the-counter) 3
5. Avoid: Simple incision and drainage (causes persistent bleeding and higher recurrence) 1, 4

Special Populations

Pregnancy

• Safe options: Dietary fiber, adequate fluid intake, psyllium husk 1
• Safe laxatives: Polyethylene glycol or lactulose 1
• Safe topical: Hydrocortisone foam in third trimester 1

Patients with Anemia from Hemorrhoidal Bleeding

• Medical management alone is insufficient 1
• Hemorrhoidectomy is indicated for definitive control 1
• Rule out other causes with colonoscopy before attributing anemia to hemorrhoids 1

Critical Pitfalls to Avoid

• Never use topical corticosteroids for more than 7 days due to risk of perianal tissue thinning 1, 2, 4
• Never attribute positive fecal occult blood or anemia to hemorrhoids until colon is adequately evaluated 1
• Never perform simple incision and drainage of thrombosed hemorrhoids (causes persistent bleeding and higher recurrence) 1, 4
• Reassess if symptoms worsen or fail to improve within 1-2 weeks of medical treatment 1, 4
• Consider other diagnoses if severe pain is present with uncomplicated hemorrhoids (suggests anal fissure, which occurs in up to 20% of patients with hemorrhoids) 1

When to Escalate Beyond Medical Management

• Failure of medical therapy after 1-2 weeks warrants office-based procedures (rubber band ligation preferred) 1, 4
• Grade III-IV hemorrhoids with persistent symptoms may require surgical hemorrhoidectomy 1, 3
• Active bleeding causing anemia requires hemorrhoidectomy for definitive control 1