What are the management options for hemorrhoids?

Management of Hemorrhoids

First-line treatment for all hemorrhoids is conservative management with increased dietary fiber (5-6 teaspoonfuls psyllium husk with 600 mL water daily) and adequate water intake to soften stool and reduce straining, combined with proper bathroom habits. 1

Initial Assessment and Classification

Hemorrhoid Types and Grading

• Internal hemorrhoids are classified by degree of prolapse: Grade I (bleeding without prolapse), Grade II (prolapse with spontaneous reduction), Grade III (requiring manual reduction), and Grade IV (irreducible prolapse) 1, 2
• External hemorrhoids typically cause symptoms only when thrombosed, presenting with acute anal pain and a palpable perianal lump 1, 3
• Perform anoscopy as part of physical examination when feasible and well tolerated to properly visualize hemorrhoids 4, 3

Critical Diagnostic Pitfalls

• Never attribute fecal occult blood or anemia to hemorrhoids until the colon is adequately evaluated with colonoscopy - hemorrhoids alone do not cause positive stool guaiac tests 1
• Anal pain is generally NOT associated with uncomplicated hemorrhoids; its presence suggests other pathology such as anal fissure (occurs in up to 20% of hemorrhoid patients) 1
• Anemia from hemorrhoidal bleeding is rare (0.5 patients/100,000 population) and demands thorough investigation 1

Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications

• Increase fiber intake to 5-6 teaspoonfuls psyllium husk with 600 mL water daily to produce soft, bulky stools 1
• Avoid straining during defecation and prolonged sitting on toilet 1
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1

Pharmacological Options

• Flavonoids (phlebotonics) relieve symptoms including bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 4, 2
• Topical analgesics provide symptomatic relief of pain and itching, though long-term efficacy data are limited 1
• Topical corticosteroids may reduce perianal inflammation but MUST be limited to ≤7 days to avoid thinning of perianal and anal mucosa 4, 1

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours of symptom onset:

• Surgical excision under local anesthesia is preferred, providing faster pain relief and lower recurrence rates compared to conservative management 1, 3, 2
• Never perform simple incision and drainage of the thrombus - this leads to persistent bleeding and higher recurrence rates 4, 3

For presentation >72 hours after onset:

• Conservative management is preferred as natural resolution has begun 1, 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks achieves 92% resolution rate (versus 45.8% with lidocaine alone) 1, 3
• Nifedipine works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Topical muscle relaxants can provide additional pain relief 4, 3

Alternative Topical Agents

• Topical nitrates show good results but are limited by high incidence of headache 4, 1
• Topical heparin significantly improves healing, though evidence is limited to small studies 4, 1

Office-Based Procedures for Internal Hemorrhoids

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure for persistent Grade I-III internal hemorrhoids after conservative management fails. 1, 2

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and follow-up duration 1
• More effective than sclerotherapy and requires fewer repeat treatments than sclerotherapy or infrared photocoagulation 1
• Band must be placed ≥2 cm proximal to dentate line to avoid severe pain 1
• Can treat up to 3 hemorrhoids per session, though many practitioners limit to 1-2 columns 1

Complications:

• Pain (5-60% of patients) is most common, typically manageable with sitz baths and over-the-counter analgesics 1
• Severe bleeding occasionally occurs when eschar sloughs (1-2 weeks post-treatment) 1
• Necrotizing pelvic sepsis is rare but serious - contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) 1

Alternative Office Procedures

• Injection sclerotherapy is suitable for Grade I-II hemorrhoids, causing fibrosis and tissue shrinkage with 70-85% short-term success but only one-third achieve long-term remission 1, 2
• Infrared photocoagulation has 67-96% success for Grade I-II hemorrhoids but requires more repeat treatments 1, 2
• Bipolar diathermy achieves 88-100% bleeding control for Grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Surgery is indicated for:

• Failure of medical and office-based therapy 1
• Symptomatic Grade III-IV hemorrhoids 1, 2
• Mixed internal and external hemorrhoids 1
• Concomitant conditions (fissure, fistula) requiring surgery 1
• Anemia from hemorrhoidal bleeding - this represents a critical threshold demanding definitive surgical intervention 1

Surgical Techniques

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard for Grade IV hemorrhoids:

• Lowest recurrence rate (2-10%) 1, 5, 2
• Ferguson closed technique associated with reduced postoperative pain and faster wound healing compared to Milligan-Morgan open technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Stapled hemorrhoidopexy:

• Faster postoperative recovery and shorter hospital stay 6
• Higher recurrence rate compared to excisional hemorrhoidectomy 5, 6
• Particularly advisable for circular hemorrhoids 6

Hemorrhoidal artery ligation (HAL/RAR):

• Better tolerance with less postoperative pain 6
• Higher recurrence rate compared to excisional hemorrhoidectomy 6

Procedures to AVOID

• Anal dilatation should be abandoned - 52% incontinence rate at 17-year follow-up with sphincter injuries 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in third trimester 1
• Safe treatments include dietary fiber, adequate fluids, and bulk-forming agents like psyllium husk 1
• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely 1
• Hydrocortisone foam is safe in third trimester with no adverse events versus placebo 1

Patients with Anemia

When hemorrhoids present with active bleeding on anoscopy and low hemoglobin:

• Hemorrhoidectomy is recommended as this represents substantial chronic blood loss requiring definitive control 1
• Blood transfusion may be needed; consider preoperative optimization if hemodynamically stable 1
• Always perform colonoscopy to rule out proximal colonic pathology before attributing anemia to hemorrhoids 1
• Do not delay definitive treatment as natural history will be continued blood loss 1

Management of Ruptured Thrombosed Hemorrhoid

Immediate Care

• Clean area gently with warm water and mild soap 7
• Apply direct pressure if active bleeding present 7
• Check vital signs, hemoglobin, and coagulation status to evaluate bleeding severity 7

Conservative Treatment

• Surgical excision is generally not necessary for already-ruptured thrombosed hemorrhoid as natural drainage has occurred 7
• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks (92% resolution rate) 7
• Short-term topical corticosteroids (≤7 days) may reduce local inflammation 7
• Increase dietary fiber and water intake 7

When to Escalate

• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is necessary 7
• Monitor for signs of infection requiring antibiotics 7
• Patients with significant bleeding or anemia require colonoscopy 7

Critical Clinical Pearls

• Never use suppository medications long-term - they provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1
• Rectal 5-ASA (mesalamine) suppositories are more effective than hydrocortisone for symptom relief (RR 0.74) 1
• Avoid incision and drainage of thrombosed hemorrhoids - always perform complete excision if surgical intervention is chosen 4, 7, 3
• Immunocompromised patients require closer monitoring due to increased risk of severe infection 7
• If symptoms persist beyond 2 weeks despite conservative management, further evaluation is necessary 7