What are the treatment options for internal and external hemorrhoids using prescription suppositories, such as Anusol-HC (hydrocortisone) or Rectocaine (lidocaine)?

Prescription Hemorrhoid Suppositories: Treatment Options and Evidence-Based Recommendations

Prescription suppositories provide limited benefit for hemorrhoids, with hydrocortisone suppositories offering only symptomatic relief and lacking strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion. 1

Key Prescription Suppository Options

Hydrocortisone Suppositories (Anusol-HC)

Hydrocortisone suppositories should be limited to short-term use (≤7 days maximum) for symptomatic relief of inflammation, but are inferior to mesalamine suppositories for internal hemorrhoids. 1

• Rectal 5-ASA (mesalamine) suppositories are more effective than hydrocortisone for symptom relief in internal hemorrhoids (relative risk 0.74 [0.61–0.90]) 1
• Hydrocortisone is effective for inducing remission in mild-moderate hemorrhoids compared to placebo, with high-quality evidence supporting short-term use 1
• Critical limitation: Long-term use causes thinning of perianal and anal mucosa, increasing injury risk 1
• Conventional corticosteroids like hydrocortisone carry potential systemic side effects with prolonged use 1
• Hydrocortisone cream USP 1% is typically applied 2-4 times daily for external use 2

Lidocaine Suppositories (Rectocaine)

Lidocaine suppositories provide symptomatic relief of local pain and itching but lack long-term efficacy data. 1

• Topical analgesics in suppository form offer symptomatic relief, though data supporting long-term effectiveness are limited 1
• Combination therapy with 0.3% nifedipine and 1.5% lidocaine ointment (applied every 12 hours for 2 weeks) shows superior efficacy (92% resolution rate) compared to lidocaine alone (45.8%) for thrombosed external hemorrhoids 1
• Lidocaine/diltiazem combination improved patient satisfaction and reduced analgesia requirements by approximately 45% after hemorrhoid banding 3

Treatment Algorithm Based on Hemorrhoid Type

For Internal Hemorrhoids (Grade I-III)

1. First-line: Conservative management with increased fiber/water intake and lifestyle modifications 1
2. Second-line: Mesalamine suppositories (1-1.5 grams per day) are preferred over hydrocortisone, with success rates showing relative risk 0.44 (0.34-0.56) versus placebo 4
3. Third-line: Short-term hydrocortisone suppositories (≤7 days) only if refractory to or intolerant of mesalamine 4
4. Procedural intervention: Rubber band ligation for persistent symptoms (70.5-89% success rate) 1

For External Hemorrhoids

Suppositories are generally ineffective for external hemorrhoids because they cannot reach the affected tissue below the dentate line. 5

• For thrombosed external hemorrhoids within 72 hours: Surgical excision under local anesthesia provides fastest relief 1, 5
• For thrombosed external hemorrhoids >72 hours: Topical 0.3% nifedipine with 1.5% lidocaine ointment (not suppository) applied every 12 hours for 2 weeks 1
• Short-term corticosteroid creams (≤7 days) may reduce local inflammation 1, 5

Critical Evidence Limitations

Over-the-counter and prescription topical agents/suppositories are widely used empirically, but clinical data supporting their effectiveness are lacking. 1

• No strong evidence suggests suppositories actually reduce hemorrhoidal swelling, bleeding, or protrusion 1
• No RCTs or cohort studies of corticosteroid suppositories specifically for hemorrhoid management were identified 4
• Benefit of corticosteroid suppositories may only be indirectly inferred from studies of corticosteroid foams or enemas 4

Important Clinical Pitfalls to Avoid

• Never use corticosteroid suppositories long-term due to risk of perianal tissue thinning and systemic side effects 1
• Do not assume suppositories will treat external hemorrhoids - they are located below the dentate line and require topical ointments instead 5
• Avoid attributing all anorectal symptoms to hemorrhoids - up to 20% of patients have concomitant anal fissures 5
• Reassess if symptoms worsen or fail to improve within 1-2 weeks - may require procedural intervention or alternative diagnosis 1, 5
• Never attribute fever to hemorrhoids alone - indicates infection requiring immediate evaluation 6

When to Escalate Beyond Suppositories

• Persistent bleeding or prolapse despite conservative management warrants rubber band ligation (89% success rate for grade I-III) 1
• Grade III-IV hemorrhoids with anemia require surgical hemorrhoidectomy (2-10% recurrence rate) 1
• Thrombosed external hemorrhoids presenting within 72 hours benefit from surgical excision rather than topical therapy 1, 5