What can be given for hemorrhoids if Preparation H (phenylephrine) doesn't work?

What to Give for Hemorrhoids When Preparation H Fails

If Preparation H (phenylephrine) doesn't work, switch to topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks, which achieves a 92% resolution rate compared to only 45.8% with lidocaine alone. 1

First-Line Topical Alternatives to Preparation H

Most Effective Topical Option

• Topical 0.3% nifedipine with 1.5% lidocaine ointment is the evidence-based, preferred treatment for hemorrhoids unresponsive to phenylephrine, applied every 12 hours for two weeks 1, 2, 3
• This combination works by relaxing internal anal sphincter hypertonicity which contributes to pain, while lidocaine provides immediate symptomatic relief 1
• No systemic side effects have been observed with topical nifedipine application 1, 3

Other Topical Options

• Topical lidocaine 5% patches can be applied to affected areas for up to 12-24 hours, delivering gradual pain relief over time 4
• Topical corticosteroid creams may reduce local perianal inflammation, but must be limited to 7 days maximum to avoid thinning of perianal and anal mucosa 1, 2, 3
• Topical nitrates show good results for pain relief but are limited by high incidence of headache (up to 50% of patients) 1, 2
• Topical heparin significantly improves healing and resolution, though evidence is limited to small studies 1, 2

Oral Medications to Add

Flavonoids (Phlebotonics)

• Flavonoids are recommended to relieve hemorrhoidal symptoms including bleeding, pain, and swelling by improving venous tone 2, 5
• Effective for controlling acute bleeding in all grades of hemorrhoids 2, 6
• Important caveat: Symptom recurrence reaches 80% within 3-6 months after cessation, so this is not a cure but symptom control 1, 5

Fiber Supplementation

• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements and reduce straining 1
• Increased dietary fiber and water intake should always accompany any pharmacological treatment 2, 3

When to Escalate Beyond Topical Treatment

Office-Based Procedures (If Medications Fail After 4 Weeks)

• Rubber band ligation is the most effective office-based procedure for grade I-III internal hemorrhoids, with success rates of 70.5-89% 1, 5
• This should be the first procedural intervention after conservative management fails 1
• Can be performed in office without anesthesia 1
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1

Surgical Referral Indications

• Failure of medical and office-based therapy after appropriate trial 1
• Symptomatic grade III-IV hemorrhoids 1, 5
• Mixed internal and external hemorrhoids 1
• Presence of anemia from hemorrhoidal bleeding 1

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days as prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 2, 3
• Never perform or request simple incision and drainage of thrombosed hemorrhoids—this leads to persistent bleeding and higher recurrence rates 1, 3
• Do not assume all anorectal symptoms are due to hemorrhoids; other conditions like anal fissures occur in up to 20% of patients with hemorrhoids 1
• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1, 3

Special Considerations for Thrombosed External Hemorrhoids

• If the hemorrhoid is thrombosed and patient presents within 72 hours of symptom onset, surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates 1, 3
• If presenting more than 72 hours after onset, conservative management with topical nifedipine/lidocaine is preferred as natural resolution has begun 1, 3

Treatment Algorithm Summary

1. Start with topical 0.3% nifedipine + 1.5% lidocaine every 12 hours for 2 weeks 1, 3
2. Add oral flavonoids for symptom control and bleeding 2, 5
3. Ensure adequate fiber and water intake (psyllium husk 5-6 teaspoonfuls with 600 mL water daily) 1
4. Consider short-term topical corticosteroids (≤7 days only) if significant inflammation 1, 2
5. If no improvement after 4 weeks, refer for rubber band ligation 1, 2
6. If grade III-IV hemorrhoids or failure of office procedures, refer for surgical hemorrhoidectomy 1, 5