What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

First-Line Conservative Management (All Grades)

Conservative management with dietary and lifestyle modifications is the mandatory first-line treatment for all hemorrhoid grades before considering any procedural intervention. 1

Key components include:

• Increased dietary fiber intake (such as psyllium husk 5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1
• Adequate water intake to maintain soft, bulky stools 1
• Avoidance of straining during defecation, which is crucial to prevent symptom exacerbation 1
• Sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Treatment Options

Systemic Medications

• Flavonoids (phlebotonics) are highly effective for relieving bleeding, pain, and swelling across all hemorrhoid grades, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2

Topical Medications

For thrombosed external hemorrhoids, topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is the most effective topical treatment, achieving 92% resolution compared to 45.8% with lidocaine alone. 1, 3

Additional topical options include:

• Topical lidocaine for symptomatic relief of local pain and itching 1, 4
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1, 3, 4
• Topical nitrates show good results for pain relief but are limited by high incidence of headache 1, 4
• Topical heparin significantly improves healing of acute hemorrhoids, though evidence is limited 1, 4

Critical pitfall: Long-term use of corticosteroid suppositories is potentially harmful and should be avoided. 1

Important note: Suppository medications provide only symptomatic relief and lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion. 1

Office-Based Procedures (Grades 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. 1, 2

• Success rates: 70.5% to 89% depending on hemorrhoid grade 1
• Technique: Band placed at least 2 cm proximal to dentate line to avoid severe pain 1
• Advantages: More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1
• Complications: Pain (5-60%, typically minor), bleeding when eschar sloughs (1-2 weeks post-treatment), abscess, urinary retention 1
• Contraindication: Immunocompromised patients (increased risk of necrotizing pelvic sepsis) 1

Alternative Office Procedures

• Injection sclerotherapy: Suitable for first and second-degree hemorrhoids, causing fibrosis and tissue shrinkage; 70-85% short-term efficacy but only one-third achieve long-term remission 1, 2
• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, but requires more repeat treatments 1, 2
• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for Surgery

Surgical hemorrhoidectomy is indicated for:

• Failure of medical and office-based therapy 1
• Symptomatic grade III or IV hemorrhoids 1, 2
• Mixed internal and external hemorrhoids 1
• Anemia from hemorrhoidal bleeding 1
• Concomitant conditions (fissure, fistula) requiring surgery 1

Surgical Options

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard for grade IV hemorrhoids and the most effective treatment overall, particularly for third-degree hemorrhoids, with the lowest recurrence rate of 2-10%. 1, 2

• Ferguson (closed) technique is associated with reduced postoperative pain and improved wound healing compared to Milligan-Morgan (open) technique 1
• Major drawback: Postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Success rate: 90-98% with low recurrence 1

Alternative surgical options:

• Stapled hemorrhoidopexy: Faster postoperative recovery but higher recurrence rate compared to excisional hemorrhoidectomy 5, 6
• Hemorrhoidal artery ligation (HAL/RAR): Better tolerance but higher recurrence rate 6

Procedures to avoid:

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

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours of symptom onset: Surgical excision under local anesthesia is the preferred treatment, providing faster pain relief and lower recurrence rates. 1, 3, 2

For presentation >72 hours after onset: Conservative management is preferred, as the natural resolution process has begun. 1, 3

Conservative management includes:

• Stool softeners 1, 2
• Oral and topical analgesics (5% lidocaine) 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 3
• Flavonoids for symptom relief 3

Critical pitfall: Simple incision and drainage of the thrombus alone is NOT recommended due to persistent bleeding and higher recurrence rates. 1, 3

Treatment Algorithm by Grade

• Grade I (bleeding, no prolapse): Conservative management → rubber band ligation if persistent 1, 5
• Grade II (prolapse with spontaneous reduction): Conservative management → rubber band ligation if persistent 1, 5
• Grade III (prolapse requiring manual reduction): Conservative management → rubber band ligation OR excisional hemorrhoidectomy 1, 5
• Grade IV (irreducible prolapse): Excisional hemorrhoidectomy or stapled hemorrhoidopexy 1, 5

Important Diagnostic Considerations

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

• Anemia from hemorrhoids is rare (0.5 patients/100,000 population) and warrants colonoscopy to rule out other pathology 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 patients with hemorrhoids) 1
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer 1, 3

Special Populations

Pregnancy

• Safe treatments during pregnancy include: dietary fiber, adequate fluid intake, bulk-forming agents (psyllium husk), osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in the third trimester 1
• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 1

Follow-Up Recommendations

If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, reassessment and further evaluation are necessary. 1, 3