What is the best way to relieve painful external hemorrhoids?

Relief of Painful External Hemorrhoids

For painful external hemorrhoids, apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks, which achieves 92% resolution compared to 45.8% with lidocaine alone. 1, 2

Immediate Conservative Measures (Start These First)

• Avoid straining during bowel movements to prevent worsening of symptoms 1, 2
• Take warm sitz baths (sitting in warm water) 2-3 times daily to reduce inflammation and discomfort 1, 3
• Increase fiber intake to 25-30 grams daily and drink adequate water (at least 8 glasses) to soften stools 4, 1
• Use stool softeners such as docusate or psyllium husk to prevent constipation 4, 3

Topical Pharmacological Treatment (Most Effective)

First-Line Topical Agent

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks is the most effective option, working by relaxing the internal anal sphincter hypertonicity that contributes to pain 1, 2
• This combination has no systemic side effects and provides both muscle relaxation (nifedipine) and local pain relief (lidocaine) 1

Alternative Topical Options

• Topical lidocaine 5% alone provides symptomatic relief of local pain and itching, though less effective than the nifedipine combination 5, 2
• Short-term topical corticosteroid creams (hydrocortisone) may reduce local inflammation, but must be limited to 7 days maximum to avoid thinning of perianal and anal mucosa 4, 1, 5
• Topical nitrates (nitroglycerin ointment) can relieve pain by decreasing anal tone, but headaches occur frequently and may limit use 1, 5
• Topical heparin has shown promise in improving healing, though evidence is limited to small studies 1, 5

Oral Medications

• Flavonoids (phlebotonics) such as diosmin or micronized purified flavonoid fraction relieve symptoms including pain and swelling, though symptom recurrence reaches 80% within 3-6 months after stopping 4, 3
• NSAIDs (ibuprofen, naproxen) are probably the most effective for pain and edema in external thrombosed hemorrhoids 6

Surgical Intervention (Timing Matters)

If Presenting Within 72 Hours of Symptom Onset

• Surgical excision under local anesthesia provides the fastest pain relief and lowest recurrence rate 1, 2, 3
• Never perform simple incision and drainage of the thrombus alone—this leads to persistent bleeding and higher recurrence rates 4, 1, 2

If Presenting After 72 Hours

• Conservative management is preferred as the natural resolution process has already begun 1, 2
• Continue with topical treatments and conservative measures as outlined above 2, 3

Critical Pitfalls to Avoid

• Do not use corticosteroid creams for more than 7 days—prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 4, 1, 5
• Do not assume all anal pain is from hemorrhoids—up to 20% of patients with hemorrhoids have concomitant anal fissures, and new-onset pain may indicate an intersphincteric abscess 4
• Avoid high-potency corticosteroid suppositories long-term as they are potentially harmful 1, 2

When to Seek Further Evaluation

• If symptoms worsen or fail to improve within 1-2 weeks of treatment, reassessment is necessary 1, 2
• If severe pain persists, significant bleeding occurs, or fever develops, further evaluation is warranted 1
• Consider colonoscopy if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 4, 1

Algorithm Summary

1. Start immediately: Sitz baths + avoid straining + increase fiber/water intake
2. Apply topically: 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks
3. Add oral medication: NSAIDs for pain and/or flavonoids for symptom relief
4. Consider timing: If within 72 hours of onset and severe pain, surgical excision is superior; if beyond 72 hours, continue conservative management
5. Reassess at 1-2 weeks: If not improving, consider procedural intervention or further evaluation