How to manage hemorrhoids?

Management of Hemorrhoids

Start with conservative management for all hemorrhoid grades—increased dietary fiber (25-30g daily), adequate water intake (8-10 glasses daily), and avoidance of straining during defecation—as this is first-line therapy regardless of hemorrhoid type or severity. 1

Initial Conservative Approach (First-Line for All Grades)

• Dietary modifications form the foundation: Increase fiber intake to 25-30 grams daily through diet or bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to produce soft, bulky stools that reduce straining 1

• Hydration is critical: Consume 8-10 glasses of water daily to complement fiber intake and prevent constipation 1

• Behavioral modifications: Avoid prolonged sitting on the toilet and straining during defecation, as these exacerbate hemorrhoidal symptoms 1

• Sitz baths: Take regular warm water soaks to reduce inflammation and discomfort 1

• Phlebotonics (flavonoids): These agents relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2

Topical Treatments for Symptomatic Relief

For External Hemorrhoids or Thrombosed Hemorrhoids

• Topical 0.3% nifedipine with 1.5% lidocaine ointment is highly effective: Apply every 12 hours for two weeks, achieving 92% resolution rate compared to 45.8% with lidocaine alone 1

• Mechanism: Nifedipine relaxes internal anal sphincter hypertonicity contributing to pain, with no systemic side effects observed 1

• Corticosteroid creams: May reduce local perianal inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1

• Alternative topical agents: Topical nitrates show good results but are limited by high incidence of headache (up to 50%); topical heparin improves healing but evidence is limited 1

For Internal Hemorrhoids

• Topical analgesics: Provide symptomatic relief of local pain and itching, though long-term efficacy data are limited 1

• Suppositories have limited evidence: They provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

Office-Based Procedures (When Conservative Management Fails)

Rubber Band Ligation (First-Line Procedural Treatment)

• Indications: Grade I-III internal hemorrhoids with persistent symptoms despite 1-2 weeks of conservative management 1, 2

• Efficacy: Success rates of 70.5-89% depending on hemorrhoid grade, making it the most effective office-based procedure 1

• Technique: Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain; up to 3 hemorrhoids can be banded in a single session, though many practitioners limit to 1-2 columns 1

• Advantages: More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1

• Complications: Pain (5-60% of patients, typically minor and manageable with sitz baths and over-the-counter analgesics), bleeding when eschar sloughs (1-2 weeks post-treatment), and rarely necrotizing pelvic sepsis 1

• Contraindications: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) have increased risk of necrotizing pelvic infection 1

Alternative Office Procedures

• Injection sclerotherapy: Suitable for grade I-II hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 2

• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, but requires more repeat treatments than rubber band ligation 1, 2

• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for Surgery

• Failure of medical and office-based therapy after appropriate conservative and procedural attempts 1

• Symptomatic grade III-IV hemorrhoids with significant prolapse 1, 2

• Mixed internal and external hemorrhoids requiring comprehensive treatment 1

• Anemia from hemorrhoidal bleeding indicating substantial chronic blood loss requiring definitive control 1

• Concomitant conditions (anal fissure, fistula) requiring surgical intervention 1

Surgical Options

• Conventional excisional hemorrhoidectomy (gold standard): Most effective treatment overall with recurrence rate of only 2-10%, particularly for grade III-IV hemorrhoids 1, 2

• 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: Postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

• Stapled hemorrhoidopexy: Associated with reduced postoperative pain, shorter operation time and hospital stay, and faster recovery, but higher recurrence rate compared to excisional hemorrhoidectomy 3

Procedures to AVOID

• Anal dilatation should be abandoned: 52% incontinence rate at 17-year follow-up and causes sphincter injuries 1

• Cryotherapy is rarely used: Prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

• Excision under local anesthesia is recommended: Provides faster pain relief and reduces risk of recurrence compared to conservative management 1, 2

• Never perform simple incision and drainage: This leads to persistent bleeding and higher recurrence rates 1

Late Presentation (>72 Hours)

• Conservative management is preferred: Treatment includes stool softeners, oral analgesics (acetaminophen or ibuprofen), and topical treatments 1, 2

• Topical 0.3% nifedipine with 1.5% lidocaine: Apply every 12 hours for two weeks for optimal symptom relief 1

• Natural resolution process has typically begun by this time, making surgical intervention less beneficial 1

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1

• Safe treatments: Dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, osmotic laxatives (polyethylene glycol or lactulose) 1

• Hydrocortisone foam: Can be used safely in third trimester with no adverse events compared to placebo 1

Immunocompromised Patients

• Increased risk of complications: Patients with uncontrolled diabetes, on immunosuppressive medications, or with neutropenia have higher risk of necrotizing pelvic infection from procedures 1

• Exercise caution with office-based procedures, particularly rubber band ligation 1

Critical Diagnostic Pitfalls to Avoid

• Never attribute fecal occult blood to hemorrhoids until colon is adequately evaluated: Hemorrhoids alone do not cause positive stool guaiac tests 1

• Anemia from hemorrhoids is rare (0.5 patients/100,000 population); investigate other causes 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), perianal abscess, or thrombosed external hemorrhoid 1

• Fever should never be attributed to hemorrhoids alone: It indicates infection requiring immediate evaluation for abscess or necrotizing pelvic sepsis 4

• Perform anoscopy when feasible to rule out other causes of anorectal symptoms frequently misattributed to hemorrhoids 1

• Consider colonoscopy if concern for inflammatory bowel disease or cancer based on patient history or physical examination 1

When to Reassess or Escalate Care

• If symptoms worsen or fail to improve within 1-2 weeks of conservative treatment, further evaluation is necessary 1

• Red flags requiring immediate evaluation: Significant bleeding, severe pain, fever, urinary retention, or signs of systemic infection 1, 4

• Severe pain with fever and urinary retention suggests necrotizing pelvic sepsis requiring emergency evaluation and broad-spectrum antibiotics 4

Role of Antibiotics

• Antibiotics are NOT indicated for uncomplicated hemorrhoids and should only be prescribed if evidence of superinfection or abscess formation exists 4

• Indications for antibiotics: Perianal abscess formation, necrotizing pelvic sepsis, or signs of systemic infection (fever >38.5°C, tachycardia, hypotension, elevated WBC) 4

• Antibiotic regimen for infection: Fluoroquinolones or third-generation cephalosporin plus metronidazole to cover Gram-negative bacteria and anaerobes 4