What are the treatment options for hemorrhoids?

Hemorrhoid Treatment

First-Line Conservative Management for All Grades

All hemorrhoid patients should begin with conservative management including increased dietary fiber (5-6 teaspoonfuls psyllium husk with 600 mL water daily), adequate fluid intake, avoidance of straining during defecation, and regular sitz baths. 1, 2

• Bulk-forming agents like psyllium husk help regulate bowel movements and soften stool, reducing mechanical trauma during defecation 1
• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Sitz baths reduce inflammation and discomfort 1

Topical Pharmacological Management

For symptomatic relief, topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution compared to 45.8% with lidocaine alone, with no systemic side effects. 1

• Nifedipine relaxes internal anal sphincter hypertonicity which contributes to pain 1
• Lidocaine provides symptomatic relief of local pain and itching 1
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1

Office-Based Procedures for 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, 3

Rubber Band Ligation Specifics:

• Success rates range from 70.5% to 89% depending on hemorrhoid grade 1, 3
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 4, 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer 1-2 columns at a time 1
• Pain occurs in 5-60% of patients but is typically minor and manageable with sitz baths and over-the-counter analgesics 1, 3

Alternative Office Procedures:

• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids, but requires more repeat treatments 1, 3
• Sclerotherapy: Suitable for grade I-II hemorrhoids, 70-85% short-term efficacy but only one-third achieve long-term remission 1, 2
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

Contraindications to Rubber Band Ligation:

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) have increased risk of necrotizing pelvic sepsis 1, 3

Surgical Management

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, hemorrhoids causing anemia, and when concomitant conditions (fissure, fistula) require surgery. 1, 3

Conventional Excisional Hemorrhoidectomy:

• Most effective treatment overall with lowest recurrence rate (2-10%), particularly for grade III-IV hemorrhoids 1, 3, 2
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques with no significant difference in outcomes 1
• Ferguson (closed) technique is associated with reduced postoperative pain and improved wound healing 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Alternative Surgical Approaches:

• Stapled hemorrhoidopexy: Faster postoperative recovery but higher recurrence rate than conventional hemorrhoidectomy 1
• Hemorrhoidal artery ligation: May cause less pain with quicker recovery for grade II-III hemorrhoids 3

Procedures to Avoid:

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

Management of Thrombosed External Hemorrhoids

For presentation within 72 hours of symptom onset, excision under local anesthesia provides faster pain relief and reduces risk of recurrence. 1

• Simple incision and drainage is NOT recommended due to persistent bleeding and higher recurrence rates 1
• For presentation >72 hours after onset, conservative management is preferred with stool softeners, oral and topical analgesics 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks shows 92% resolution rate 1

Treatment Algorithm by Hemorrhoid Grade

Grade I (bleeding, no prolapse):

1. Conservative management (fiber, fluids, lifestyle modifications) 1, 3
2. If persistent: Infrared photocoagulation or sclerotherapy 3
3. If failed: Rubber band ligation 3

Grade II (prolapse with spontaneous reduction):

1. Conservative management 1, 3
2. If persistent: Rubber band ligation as preferred office-based procedure 1, 3
3. If failed: Surgical hemorrhoidectomy 3

Grade III (prolapse requiring manual reduction):

1. Conservative management 1, 3
2. If persistent: Rubber band ligation 1, 3
3. If failed: Surgical hemorrhoidectomy (conventional excisional, stapled hemorrhoidopexy, or hemorrhoidal artery ligation) 1, 3

Grade IV (irreducible prolapse):

1. Surgical hemorrhoidectomy typically required 3
2. Conventional excisional hemorrhoidectomy offers lowest recurrence rate 1, 3

Special Populations

Pregnancy:

• 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

Hemorrhoids with Anemia:

• Hemorrhoidectomy is indicated for patients with anemia from hemorrhoidal bleeding, as this represents a critical threshold demanding definitive surgical intervention 1
• Colonoscopy should be performed to rule out proximal colonic pathology before attributing anemia to hemorrhoids 1
• Blood transfusion may be needed given low hemoglobin levels 1

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without adequate colon evaluation 1
• Never use corticosteroid creams for more than 7 days as prolonged use causes thinning of perianal and anal mucosa 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), thrombosed external hemorrhoid, or perianal abscess 1
• Fever should never be attributed to hemorrhoids alone, as it indicates infection requiring immediate evaluation for abscess or necrotizing pelvic sepsis 5
• Antibiotics should only be prescribed if there is evidence of superinfection or abscess formation, which is exceedingly rare in hemorrhoidal disease 5