Flavonoids for Hemorrhoids
Flavonoids should be used to relieve symptoms in patients with complicated hemorrhoids, including bleeding, pain, swelling, and inflammation, based on moderate-quality evidence from international guidelines. 1
Evidence Supporting Flavonoid Use
The World Society of Emergency Surgery (WSES) and American Association for the Surgery of Trauma (AAST) 2021 guidelines specifically recommend administering flavonoids to relieve symptoms in patients with complicated hemorrhoids (weak recommendation based on moderate quality evidence, 2B). 1 This recommendation is supported by:
A Cochrane meta-analysis of 24 randomized controlled trials (2,334 participants) demonstrated that phlebotonics (including flavonoids like diosmin) showed statistically significant beneficial effects for pruritus, bleeding, post-hemorrhoidectomy bleeding, discharge and leakage, and overall symptom improvement. 1
FDA drug label data for diosmin shows that multiple studies involving several hundred patients routinely demonstrated that diosmin reduces symptoms of discomfort, swelling, inflammation and time to resolution compared to standard of care, shortening resolution time of acute flares from 8 days to 4-5 days. 2
Specific Clinical Applications
For Acute Hemorrhoidal Episodes
Diosmin is effective for controlling acute bleeding in all grades of hemorrhoids, with a double-blind, placebo-controlled study (n=120) showing statistically better management of pain, pruritus, discharge, edema, erythema, and bleeding. 2
For bleeding cessation in grades I, II, and III internal hemorrhoids, combining infrared photocoagulation with diosmin achieved 75% success at 5 days versus 60% with diosmin alone or 56% with photocoagulation alone (n=351). 2
Patients with grades I and II hemorrhoids respond significantly better (83% and 62%, respectively) to flavonoid therapy than those with grade III hemorrhoids (23%). 2
For Grade II and III Hemorrhoidal Disease
A compound of micronized flavonoids with vitamin C and herbal extracts resulted in 89.8% of patients (44/49) showing reduction in hemorrhoidal grade by at least one degree after 7 days of treatment, with significant reduction in all anorectal symptoms (p < 0.05). 3
A multicenter Russian study (n=1952) found MPFF-based conservative treatment effective in 76.3% of patients for eliminating bleeding and prolapse of internal nodes, with highest efficacy in grades I and II hemorrhoids. 4
Dosing and Duration
Standard dosing regimens include diosmin 1800 mg per day or micronized purified flavonoid fraction (MPFF) at recommended doses for 7 days during acute episodes. 5
There is no conclusive evidence to prefer 3000 mg per day of micronized fraction of flavonoids compared with 1800 mg of purified diosmin per day for acute hemorrhoids. 5
Integration with Other Treatments
Flavonoids should always be combined with:
Increased dietary fiber and water intake to soften stool and reduce straining. 6, 7
Topical treatments such as 0.3% nifedipine with 1.5% lidocaine ointment for thrombosed hemorrhoids (92% resolution rate). 6, 7
Short-term topical corticosteroids (≤7 days) for local inflammation, avoiding prolonged use to prevent perianal tissue thinning. 6, 7
Important Limitations and Caveats
Flavonoids do not cure hemorrhoids—the prime objective is to control the acute phase (bleeding) so that definitive therapy can be scheduled at a convenient time. 8
Symptom recurrence reaches 80% within 3-6 months after cessation of flavonoid therapy, indicating need for ongoing management or definitive treatment. 6
Pain relief may not reach statistical significance, though benefits for bleeding, pruritus, and overall symptoms are well-established. 1
Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology, as hemorrhoids alone rarely cause anemia (0.5 patients/100,000 population). 6
When to Escalate Beyond Flavonoids
If symptoms worsen or fail to improve within 1-2 weeks, reassessment and consideration of office-based procedures (rubber band ligation, sclerotherapy) or surgical intervention is warranted. 6
For grade III-IV hemorrhoids with persistent bleeding despite medical therapy, surgical hemorrhoidectomy provides the most definitive treatment with lowest recurrence rates (2-10%). 6
Thrombosed external hemorrhoids presenting within 72 hours should be considered for surgical excision rather than medical management alone for faster symptom resolution and lower recurrence. 6