What are the treatment options for hemorrhoids?

Treatment for Hemorrhoids

First-line treatment for all hemorrhoids is conservative management with increased dietary fiber and water intake to soften stool and reduce straining, followed by office-based rubber band ligation for persistent grade I-III internal hemorrhoids, and surgical hemorrhoidectomy for grade III-IV disease or when conservative measures fail. 1

Conservative Management (First-Line for All Grades)

All patients should begin with dietary and lifestyle modifications regardless of hemorrhoid grade or type. 1

Core Conservative Measures

• Increase fiber intake to 5-6 teaspoonfuls of psyllium husk with 600 mL water daily to produce soft, bulky stools and reduce straining 1
• Ensure adequate water intake throughout the day to complement fiber supplementation 1
• Avoid straining during defecation, which exacerbates hemorrhoidal symptoms 1
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Adjuncts for Symptom Relief

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1
• Topical lidocaine provides symptomatic relief of local pain and itching 1
• Topical corticosteroid creams may reduce perianal inflammation but MUST be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1

Important caveat: Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion, and long-term use of high-potency corticosteroid suppositories is potentially harmful 1

Office-Based Procedures (For Persistent Grade I-III Internal Hemorrhoids)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention when conservative management fails, with success rates of 70.5-89% depending on hemorrhoid grade 1

Rubber Band Ligation Technique

• The band is placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Can be performed in an office setting without anesthesia 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer 1-2 columns at a time 1
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1

Complications to Monitor

• Pain is the most common complication (5-60% of patients) but is typically manageable with sitz baths and over-the-counter analgesics 1
• Severe bleeding occasionally occurs when the eschar sloughs, typically 1-2 weeks after treatment 1
• Contraindicated in immunocompromised patients (including those with uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1

Alternative Office-Based Procedures

• Injection sclerotherapy is suitable for first and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage, with 70-85% short-term efficacy but only one-third achieving long-term remission 1, 2
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management (For Grade III-IV or Failed Conservative/Office-Based Treatment)

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and when anemia from hemorrhoidal bleeding occurs. 1

Indications for Surgery

• Failure of conservative and office-based approaches 1
• Symptomatic grade III or IV hemorrhoids 1
• Mixed internal and external hemorrhoids 1
• Anemia from hemorrhoidal bleeding (represents a critical threshold demanding definitive intervention) 1
• Concomitant conditions (fissure, fistula) requiring surgery 1

Surgical Techniques

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard for grade IV hemorrhoids, with recurrence rates of only 2-10% 1
• Ferguson (closed) technique involves excising hemorrhoid components and closing wounds primarily, associated with reduced postoperative pain and faster wound healing compared to Milligan-Morgan (open) technique 1
• Stapled hemorrhoidopexy has faster postoperative recovery but higher recurrence rates 3, 2

Postoperative Considerations

• Narcotic analgesics are generally required for postoperative pain management 1
• Most patients do not return to work for 2-4 weeks following surgery 1
• Success rate approaches 90-98% with low recurrence for hemorrhoidectomy 1

Procedures to AVOID

• Anal dilatation should NEVER be performed due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1
• Cryotherapy should be avoided due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Management of Thrombosed External Hemorrhoids

The treatment approach depends critically on timing of presentation.

Early Presentation (Within 72 Hours)

• Surgical excision under local anesthesia is the preferred treatment, providing faster symptom resolution and lower recurrence rates 4
• NEVER perform simple incision and drainage of the thrombus alone - this leads to persistent bleeding and higher recurrence rates 4

Late Presentation (>72 Hours)

• Conservative management is preferred as the natural resolution process has begun 4
• Treatment includes stool softeners, oral and topical analgesics 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) compared to 45.8% with lidocaine alone 4
• Topical nitrates show good results but are limited by high incidence of headache 4
• Short-term topical corticosteroids (≤7 days) can reduce local inflammation 4

Treatment Algorithm Based on Hemorrhoid Grade

Grade I (Bleeding but not protruding)

• Conservative management with fiber, fluids, and lifestyle modifications 1
• If persistent: rubber band ligation, sclerotherapy, or infrared photocoagulation 1

Grade II (Prolapse with spontaneous reduction)

• Conservative management first 1
• If persistent: rubber band ligation (most effective office-based procedure) 1
• Alternative: sclerotherapy or infrared photocoagulation 1

Grade III (Requiring manual reduction)

• Conservative management trial first 1
• Rubber band ligation for persistent symptoms 1
• Surgical hemorrhoidectomy if office-based procedures fail or for mixed disease 1

Grade IV (Irreducible)

• Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) is the gold standard, with recurrence rate of only 2-10% 1

Special Populations

Pregnant Patients

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
• Osmotic laxatives such as polyethylene glycol or lactulose can be used safely 1
• Hydrocortisone foam can be used safely in third trimester with no adverse events 1

Patients with Anemia

• Hemorrhoidectomy is recommended for patients with anemia from hemorrhoidal bleeding 1
• Never attribute anemia to hemorrhoids without proper evaluation - colonoscopy should be performed to rule out proximal colonic pathology 1
• Blood transfusion may be needed given low hemoglobin levels 1

Critical Pitfalls to Avoid

• 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) - always investigate other causes 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
• Colonoscopy should be considered if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 4