What are the management options for hemorrhoids?

Hemorrhoid Management

First-Line Conservative Management for All Hemorrhoid Types

All hemorrhoid grades should initially be managed with dietary and lifestyle modifications, including increased fiber and water intake to soften stool and reduce straining during defecation. 1, 2

• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements and are safe even during pregnancy 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3
• Warm sitz baths reduce inflammation and discomfort 1

Topical Pharmacological Management

For External or Thrombosed Hemorrhoids

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, 2

• Nifedipine relaxes internal anal sphincter hypertonicity that contributes to pain 1
• Lidocaine provides symptomatic relief of local pain and itching 1, 2
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1, 2
• Topical nitrates show good results but are limited by high incidence (up to 50%) of headache 1
• Topical heparin significantly improves healing, though evidence is limited to small studies 1

Critical Pitfall

Never use corticosteroid creams for more than 7 days—prolonged use causes tissue thinning and increased injury risk. 1, 2

Office-Based Procedures for Grade 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, with success rates of 70.5% to 89%. 1, 3

• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 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 limit treatment to 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients) but is typically manageable with sitz baths and over-the-counter analgesics 1
• Repeated banding is needed in up to 20% of patients 3

Alternative Office Procedures

• Injection sclerotherapy is suitable for first and second-degree hemorrhoids, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 3
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1, 3
• Bipolar diathermy has 88-100% success rates 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 infection and should not undergo rubber band ligation. 1

Surgical Management

Indications for Hemorrhoidectomy

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

• Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with low recurrence rates of 2-10%. 1, 3
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques; Ferguson technique is associated with reduced postoperative pain and improved wound healing 1, 4
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Stapled hemorrhoidopexy has faster postoperative recovery but higher recurrence rates 5, 4

Critical Surgical Pitfalls

Never perform anal dilatation—it causes 52% incontinence rate at 17-year follow-up and sphincter injuries. 1

Avoid cryotherapy due to prolonged pain, foul-smelling discharge, and greater need for additional therapy. 1

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours of symptom onset: surgical excision under local anesthesia provides faster pain relief and reduced recurrence risk. 2, 3

For presentation >72 hours after onset: conservative management is preferred as natural resolution has begun. 2, 3

• Conservative management includes stool softeners, oral analgesics (acetaminophen or ibuprofen), and topical 0.3% nifedipine with 1.5% lidocaine 1, 2
• Never perform simple incision and drainage of the thrombus—this leads to persistent bleeding and higher recurrence rates 1, 2

For Ruptured Thrombosed Hemorrhoids

• Clean the area gently with warm water and mild soap 6
• Apply direct pressure if active bleeding is present 6
• Surgical excision is generally not necessary as natural drainage has occurred 6
• Continue conservative management with topical nifedipine/lidocaine and short-term corticosteroids (≤7 days) 6

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, and osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in third trimester with no adverse events 1

Patients with Anemia

When hemorrhoidal bleeding causes anemia, hemorrhoidectomy is indicated as it represents a critical threshold demanding definitive surgical intervention. 1

• Active bleeding on anoscopy with low hemoglobin indicates substantial chronic blood loss requiring definitive control 1
• Never attribute anemia to hemorrhoids without proper evaluation—colonoscopy should be performed to rule out proximal colonic pathology 1
• Blood transfusion may be needed given low hemoglobin levels 1

Red Flags Requiring Further Evaluation

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, 2

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) 1
• Anal pain is generally not associated with uncomplicated hemorrhoids—its presence suggests other pathology such as anal fissure, which occurs in up to 20% of patients with hemorrhoids 1
• Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis requiring emergency evaluation 1