What treatment options are available for hemorrhoids?

Treatment Options for Hemorrhoids

For uncomplicated hemorrhoids, start with increased dietary fiber (5-6 teaspoonfuls psyllium husk with 600 mL water daily) and adequate hydration, combined with topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks, which achieves 92% resolution rates. 1, 2

First-Line Conservative Management

Dietary and Lifestyle Modifications:

• Increase fiber intake to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to produce soft, bulky stools 2
• Maintain adequate fluid intake throughout the day 1, 2
• Avoid straining during defecation, which worsens hemorrhoidal congestion 3, 2
• Take regular warm sitz baths (15-20 minutes, 2-3 times daily) to reduce inflammation and discomfort 2

Topical Pharmacological Treatment:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment is the most effective topical treatment, applied every 12 hours for two weeks, achieving 92% resolution compared to 45.8% with lidocaine alone 3, 1, 4
• This combination works by relaxing internal anal sphincter hypertonicity (nifedipine) while providing immediate pain relief (lidocaine), with no systemic side effects 3, 2
• Short-term topical corticosteroids (hydrocortisone cream) may be used for perianal inflammation, but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 3, 1, 5

Oral Medications:

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 6
• Stool softeners like docusate sodium can reduce straining 7

Treatment Algorithm Based on Hemorrhoid Type and Grade

For Thrombosed External Hemorrhoids:

Timing is critical for treatment decisions:

• If presenting within 72 hours of symptom onset: Surgical excision under local anesthesia provides fastest symptom resolution and lowest recurrence rates 1, 4, 6
• If presenting after 72 hours: Conservative management is preferred as natural resolution has begun 1, 4
  • Use topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1, 4
  • Add oral analgesics and stool softeners 6
  • Warm sitz baths 2-3 times daily 2

Critical pitfall: Never perform simple incision and drainage of the thrombus alone—this leads to persistent bleeding and higher recurrence rates 3, 1, 4

For Internal Hemorrhoids (Grade I-III):

If conservative management fails after 1-2 weeks:

• Rubber band ligation is the first-line office procedure, with success rates of 70.5-89% depending on hemorrhoid grade 2, 6
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 2
• Can treat up to 3 hemorrhoids per session, though many practitioners limit to 1-2 columns 2
• Must place bands at least 2 cm proximal to dentate line to avoid severe pain 2

Alternative office procedures if rubber band ligation fails or is contraindicated:

• Injection sclerotherapy for grade I-II hemorrhoids: 70-85% short-term efficacy, but only one-third achieve long-term remission 6
• Infrared photocoagulation for grade I-II hemorrhoids: 67-96% success rates 2

For Internal Hemorrhoids (Grade III-IV) or Failed Conservative/Office Treatment:

Surgical hemorrhoidectomy is indicated for: 2, 6

• Failure of medical and office-based therapy
• Symptomatic grade III-IV hemorrhoids
• Mixed internal and external hemorrhoids
• Hemorrhoids causing anemia from chronic bleeding
• Concomitant conditions (fissure, fistula) requiring surgery

Surgical options:

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique): 2-10% recurrence rate, most effective overall 2, 6
• Stapled hemorrhoidopexy: Less postoperative pain, faster recovery, but higher recurrence rates 8
• Hemorrhoidal artery ligation (HAL/RAR): Better tolerance but higher recurrence 8

Special Populations

Pregnancy:

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in third trimester 2
• Safe treatments include dietary fiber, adequate fluids, psyllium husk, and osmotic laxatives (polyethylene glycol or lactulose) 2
• Hydrocortisone foam can be used safely in third trimester with no adverse events 2

Patients on anticoagulation or with cirrhosis:

• Requires careful evaluation and potential hematology consultation before any procedural intervention 9

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to rule out proximal colonic pathology 2
• Avoid long-term corticosteroid use (>7 days) due to risk of perianal tissue thinning and increased injury risk 3, 1, 5
• Do not assume all anorectal symptoms are hemorrhoids—anal fissures coexist in up to 20% of patients and cause pain, which uncomplicated hemorrhoids do not 2
• Avoid anal dilation—causes 52% incontinence rate at 17-year follow-up 2
• Avoid cryotherapy—causes prolonged pain, foul-smelling discharge, and requires more additional therapy 2

When to Reassess or Refer

• If symptoms worsen or fail to improve within 1-2 weeks of conservative treatment 1, 4
• Presence of severe bleeding, severe pain, or fever 2
• Signs of infection requiring antibiotics 1
• Significant bleeding causing hemodynamic instability or anemia 2
• Immunocompromised patients require closer monitoring due to increased infection risk 1