What is the recommended treatment for haemorrhoids?

Treatment of Haemorrhoids

First-Line Conservative Management for All Grades

All patients with haemorrhoids should begin with conservative management consisting of increased dietary fiber (5-6 teaspoonfuls of psyllium husk with 600 mL water daily), adequate water intake to soften stool, and avoidance of straining during defecation. 1, 2

• This approach is recommended as first-line therapy regardless of haemorrhoid grade or type (internal vs external) 1, 2
• Dietary fiber supplementation prevents progression and reduces bleeding episodes 2
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1
• These modifications alone may resolve symptoms in many patients without need for procedural intervention 1

Topical Pharmacological Management

For Symptomatic Relief and Thrombosed Haemorrhoids

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, 2, 3

• This combination works by relaxing internal anal sphincter hypertonicity while providing local pain relief 1
• No systemic side effects have been observed with topical nifedipine 1
• This is particularly effective for thrombosed external haemorrhoids 1, 3

Corticosteroid Use (Limited Duration Only)

• Short-term topical corticosteroids (≤7 days maximum) can reduce perianal inflammation 1, 2, 3
• Never use corticosteroids for more than 7 days due to risk of perianal and anal mucosa thinning 1, 2, 3
• Long-term use of high-potency corticosteroid suppositories is potentially harmful and should be avoided 1, 3

Alternative Topical Agents

• Topical nitrates show good results but are limited by high incidence of headache 1
• Topical heparin may improve healing though evidence is limited 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, but symptom recurrence reaches 80% within 3-6 months after cessation 1, 4

Office-Based Procedures for Grades I-III Internal Haemorrhoids

When Conservative Management Fails

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal haemorrhoids, with success rates of 70.5-89%. 1, 2, 4

• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• Can be performed in office without anesthesia 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Up to 3 haemorrhoids can be banded in a single session, though many practitioners limit to 1-2 columns 1
• Repeated banding may be needed in up to 20% of patients 4

Alternative Office Procedures (When Rubber Band Ligation Inappropriate)

• Injection sclerotherapy is suitable for first and second-degree haemorrhoids, achieving 70-85% short-term success but only one-third achieve long-term remission 1, 4
• Infrared photocoagulation has 67-96% success rates for grade I-II haemorrhoids but requires more repeat treatments 1, 4
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II haemorrhoids 1

Contraindications to Rubber Band Ligation

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic infection 1

Surgical Management

Indications for Hemorrhoidectomy

Conventional excisional hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV haemorrhoids, mixed internal and external haemorrhoids, and when anemia from haemorrhoidal bleeding is present. 1, 2, 4

• This is the most effective treatment overall with lowest recurrence rate of 2-10% 1, 2, 4
• Particularly effective for third-degree haemorrhoids 1, 2
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques with no significant difference in outcomes 1
• The Ferguson (closed) technique is associated with reduced postoperative pain and improved wound healing 1

Postoperative Considerations

• Narcotic analgesics are generally required for postoperative pain 1
• Most patients do not return to work for 2-4 weeks following surgery 1
• Recovery time is 9-14 days 4

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 Haemorrhoids

Timing-Based Algorithm

For thrombosed external haemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia is the preferred treatment, providing faster symptom resolution and lower recurrence rates. 2, 3, 4

• Outpatient clot evacuation within 72 hours is associated with decreased pain and reduced risk of repeat thrombosis 4
• Simple incision and drainage of the thrombus alone is NOT recommended due to persistent bleeding and higher recurrence rates 1, 3

For Presentation >72 Hours After Onset

Conservative management is preferred for thrombosed haemorrhoids presenting more than 72 hours after symptom onset, as the natural resolution process has begun. 1, 3, 4

• Treatment includes stool softeners, oral and topical analgesics (5% lidocaine) 1, 4
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 2, 3
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1, 3

Special Populations

Pregnancy

• Haemorrhoids 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 (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 from Haemorrhoidal Bleeding

Hemorrhoidectomy is recommended for patients with anemia from haemorrhoidal bleeding, as this represents a critical threshold demanding definitive surgical intervention. 1

• Active bleeding with low hemoglobin indicates substantial chronic blood loss requiring definitive control 1
• Success rate approaches 90-98% with low recurrence for this indication 1
• Blood transfusion may be needed, and preoperative optimization should be considered if hemodynamically stable 1

Critical Diagnostic Considerations

When to Pursue Further Evaluation

• Haemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to haemorrhoids until the colon is adequately evaluated 1
• Anemia due to haemorrhoidal disease is rare (0.5 patients/100,000 population) 1
• Anal pain is generally not associated with uncomplicated haemorrhoids; its presence suggests other pathology such as anal fissure (occurs in up to 20% of patients with haemorrhoids) 1
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 2, 3
• Adults older than 50 years with rectal bleeding should undergo colonoscopy to exclude cancer 5

Physical Examination

• Anoscopy should be performed when feasible and well tolerated to assess for internal haemorrhoids 2, 3
• Digital rectal examination to rule out other causes of lower gastrointestinal bleeding 2
• Check vital signs, hemoglobin, hematocrit, and coagulation parameters to evaluate bleeding severity 2