What are the management options for hemorrhoids?

Management of Hemorrhoids

First-Line Conservative Management for All Grades

All hemorrhoid patients should begin with conservative management consisting of increased dietary fiber and water intake to produce soft, bulky stools, combined with avoidance of straining during defecation. 1, 2, 3

• Fiber supplementation with bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) is the cornerstone of treatment 1
• This approach is recommended regardless of hemorrhoid grade or type (internal vs external) 1, 3
• Phlebotonics (flavonoids) can relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 4

Topical Pharmacological Management

For symptomatic relief, 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, making it the most effective topical treatment. 1, 2

• Nifedipine works by relaxing internal anal sphincter hypertonicity without systemic side effects 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, 3
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1
• Topical lidocaine 5% patches can be used for up to 12-24 hours for gradual pain relief 1

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 when conservative management fails, with success rates of 70.5-89%. 1, 3, 4

• 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
• Rubber band ligation is more effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• Pain is the most common complication (5-60% of patients) but is typically manageable with sitz baths and over-the-counter analgesics 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1

Alternative Office Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 4
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1, 4
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management

Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) is indicated for grade III-IV hemorrhoids, failure of medical and office-based therapy, mixed internal and external hemorrhoids, or when anemia has developed from hemorrhoidal bleeding. 1, 3, 4

• Recurrence rates are low at 2-10%, making this the most definitive treatment 1, 4
• Ferguson (closed) technique is associated with reduced postoperative pain and faster wound healing compared to Milligan-Morgan (open) technique 1, 5
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Stapled hemorrhoidopexy (Longo procedure) offers reduced postoperative pain and faster recovery but has higher recurrence rates 5

Procedures to Avoid

• Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up 1, 5
• Cryotherapy should be avoided due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 5

Management of Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, surgical excision under local anesthesia provides faster pain relief and lower recurrence rates. 1, 2, 4

• Simple incision and drainage is NOT recommended due to persistent bleeding and higher recurrence rates 1, 2, 3
• For presentation >72 hours after onset, conservative management is preferred as natural resolution has begun 1, 2
• Conservative management includes stool softeners, oral analgesics, and topical 0.3% nifedipine with 1.5% lidocaine ointment 1, 2, 4

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, most 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 the third trimester with no adverse events 1

Hemorrhoids with Anemia

When hemorrhoidal bleeding has caused anemia, hemorrhoidectomy is indicated as this represents a critical threshold demanding definitive surgical intervention. 1

• Check vital signs, complete blood count, and coagulation studies to assess bleeding severity 1, 3
• Blood transfusion may be needed preoperatively if hemodynamically unstable 1
• Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1

Critical Diagnostic Considerations

• 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, 3
• Anemia from 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
• Anoscopy should be performed when feasible and well tolerated 2, 3
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer 2, 3

When to Reassess or Escalate Care

• If symptoms worsen or fail to improve within 1-2 weeks of treatment, reassessment is necessary 1, 2
• Presence of severe pain, high fever, and urinary retention suggests necrotizing pelvic sepsis requiring emergency evaluation 1
• Significant bleeding, severe pain, or fever warrant further evaluation 1