What are the treatment options for hemorrhoids?

Hemorrhoid Treatment

For symptomatic hemorrhoids, begin with conservative management (increased fiber, water intake, and lifestyle modifications) for all grades, then escalate to rubber band ligation for persistent grade I-III internal hemorrhoids, and reserve surgical hemorrhoidectomy for grade IV hemorrhoids or when office-based procedures fail. 1

Conservative Management (First-Line for All Grades)

• Dietary and lifestyle modifications are the foundation of hemorrhoid treatment and should be initiated in all patients regardless of hemorrhoid grade. 1
• Increase dietary fiber to 25-30g daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining. 1
• Ensure adequate water intake (at least 8 glasses daily) to complement fiber supplementation. 1
• Avoid prolonged sitting on the toilet and straining during defecation. 1
• Regular sitz baths (warm water soaks for 10-15 minutes, 2-3 times daily) reduce inflammation and provide symptomatic relief. 1

Topical Treatments for Symptom Relief

• For external hemorrhoids or thrombosed 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
• This combination works by relaxing internal anal sphincter hypertonicity (nifedipine) while providing local pain relief (lidocaine), with no systemic side effects reported. 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 efficacy but are limited by high incidence of headache (up to 50% of patients). 1

Office-Based Procedures (For Persistent Grade I-III Internal Hemorrhoids)

Rubber Band Ligation (Preferred First-Line Procedure)

• Rubber band ligation is the most effective office-based procedure for grade I-III internal hemorrhoids, with success rates of 70.5-89% depending on hemorrhoid grade. 1
• The procedure involves placing a tight band at least 2 cm proximal to the dentate line to encircle redundant mucosa, causing tissue necrosis and subsequent scarring that fixes tissue to the rectal wall. 1
• Can be performed in office without anesthesia; treat 1-2 hemorrhoid columns per session to minimize complications. 1
• Rubber band ligation is more effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation or sclerotherapy. 2

Complications and Management:

• Pain occurs in 5-60% of patients but is typically minor and manageable with sitz baths and over-the-counter analgesics (acetaminophen or ibuprofen). 1
• Severe bleeding may occur when the eschar sloughs (typically 1-2 weeks post-procedure). 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic sepsis. 1
• The clinical triad of severe pain, high fever, and urinary retention suggests necrotizing pelvic sepsis requiring emergency intervention. 3

Alternative Office-Based Procedures

• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments than rubber band ligation. 1
• Bipolar diathermy achieves 88-100% success rates for bleeding control in grade II hemorrhoids. 1
• Injection sclerotherapy is suitable for grade I-II hemorrhoids but is less effective than rubber band ligation. 1

Surgical Management

Indications for Surgery

• Surgical hemorrhoidectomy is indicated for: failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, or when concomitant conditions (fissure, fistula) require surgery. 1
• Hemorrhoidectomy is specifically indicated when hemorrhoidal bleeding has caused anemia, as this represents substantial chronic blood loss requiring definitive control. 1

Conventional Excisional Hemorrhoidectomy (Gold Standard)

• Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with the lowest recurrence rate of 2-10%. 1
• Ferguson (closed) technique involves excising hemorrhoid components and closing wounds primarily, associated with reduced postoperative pain and faster wound healing compared to Milligan-Morgan (open) technique. 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 may cause less postoperative pain with quicker recovery for grade II-III hemorrhoids but has higher recurrence rates than conventional hemorrhoidectomy. 1
• Hemorrhoidal artery ligation (HAL) with or without recto-anal repair (RAR) shows similar trends of better tolerance but higher recurrence rates. 1

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

Early Presentation (Within 72 Hours)

• For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia provides the most rapid symptom resolution and lower recurrence rates. 1
• Never perform simple incision and drainage of the thrombus alone—this leads to persistent bleeding and higher recurrence rates. 1

Late Presentation (>72 Hours)

• For presentation beyond 72 hours or when pain is improving, conservative management is preferred with stool softeners, oral analgesics, and topical 0.3% nifedipine with 1.5% lidocaine ointment. 1
• The natural resolution process has typically begun by this time, making surgical intervention less beneficial. 1

Treatment Algorithm by Hemorrhoid Grade

Grade I (Bleeding Without Prolapse)

• Start with conservative management (fiber, fluids, lifestyle modifications). 4
• If symptoms persist, consider infrared photocoagulation or sclerotherapy. 4
• Rubber band ligation if other methods fail. 4

Grade II (Prolapse With Spontaneous Reduction)

• Start with conservative management. 4
• Rubber band ligation is the preferred office-based procedure if conservative measures fail. 4

Grade III (Prolapse Requiring Manual Reduction)

• Start with conservative management. 4
• Rubber band ligation if symptoms persist. 4
• Surgical hemorrhoidectomy if office procedures fail or for mixed internal/external hemorrhoids. 4

Grade IV (Irreducible Prolapse)

• Surgical hemorrhoidectomy is typically required, with conventional excisional hemorrhoidectomy offering the lowest recurrence rate. 4

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without proper evaluation—colonoscopy should be performed to rule out proximal colonic pathology. 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). 1
• Do not delay definitive treatment when active bleeding has caused anemia, as the natural history will be continued blood loss. 1
• Avoid long-term use of corticosteroid preparations (>7 days) due to risk of perianal tissue thinning. 1

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the 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 the third trimester with no adverse events. 1