What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

All hemorrhoids should initially be managed with conservative measures including increased dietary fiber (5-6 teaspoonfuls of psyllium husk with 600 mL water daily), adequate hydration, and avoidance of straining during defecation, as this is first-line therapy regardless of hemorrhoid grade or type. 1, 2

Conservative Management (First-Line for All Grades)

• Dietary fiber supplementation prevents hemorrhoid progression and reduces bleeding episodes, with psyllium husk being the preferred agent 1, 2
• Adequate water intake (at least 600 mL with fiber) softens stool and reduces straining 1, 2
• Proper bathroom habits include avoiding prolonged sitting on the toilet and not straining during defecation 1, 2
• Sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1

Pharmacological Treatment Options

For All Hemorrhoid Types

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3, 4
• Topical analgesics (lidocaine 5%) provide symptomatic relief of local pain and itching, though long-term efficacy data are limited 1, 3

For External and Thrombosed Hemorrhoids

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone, with no systemic side effects 1, 2, 3
• Topical corticosteroid creams 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% of patients) 1, 3
• Topical heparin significantly improves healing, though evidence is limited to small studies 1, 3

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

Rubber Band Ligation (First-Line Procedural Treatment)

• Rubber band ligation is the most effective office-based procedure with success rates of 70.5-89%, superior to sclerotherapy and requiring fewer repeat treatments than infrared photocoagulation 1, 2, 4
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Can be performed in office without anesthesia, treating 1-2 hemorrhoid columns per session 1
• Complications include minor pain (5-60% of patients, manageable with sitz baths and over-the-counter analgesics), band slippage, and rarely necrotizing pelvic sepsis in immunocompromised patients 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, achieving 70-85% short-term success 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

Indications for Surgery

• Hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, hemorrhoids with anemia from bleeding, and when concomitant conditions (fissure, fistula) require surgery 1, 2

Surgical Techniques

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall with the lowest recurrence rate of 2-10%, particularly for grade III-IV hemorrhoids 1, 2, 4
• Ferguson (closed) technique is associated with reduced postoperative pain and improved 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
• Stapled hemorrhoidopexy and hemorrhoidal artery ligation are alternative minimally invasive options with reduced postoperative pain but higher recurrence rates 1, 5, 6

Procedures to Avoid

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

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

• Surgical excision under local anesthesia is recommended for thrombosed external hemorrhoids presenting within 72 hours, providing faster pain relief and reducing risk of recurrence 1, 2, 4, 7
• Never perform simple incision and drainage alone—this leads to persistent bleeding and higher recurrence rates 1

Late Presentation (>72 Hours)

• Conservative management is preferred with stool softeners, oral analgesics, and topical treatments 1, 4
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks is highly effective 1, 2
• Symptoms typically improve within 1-2 weeks with conservative management 1

Treatment Algorithm Based on Hemorrhoid Grade

Grade I (Bleeding, No Prolapse)

• Conservative management with fiber, fluids, and lifestyle modifications 1, 2
• Add flavonoids if bleeding persists 3, 4
• Consider rubber band ligation or sclerotherapy if conservative measures fail after 4-6 weeks 1, 4

Grade II (Prolapse with Spontaneous Reduction)

• Conservative management initially 1, 2
• Rubber band ligation is first-line procedural treatment if symptoms persist 1, 2, 4
• Alternative: infrared photocoagulation or sclerotherapy 1, 4

Grade III (Prolapse Requiring Manual Reduction)

• Rubber band ligation is first-line procedural treatment 1, 2, 4
• Surgical hemorrhoidectomy is indicated if office procedures fail or if patient has anemia from bleeding 1, 2

Grade IV (Irreducible Prolapse)

• Conventional excisional hemorrhoidectomy is the treatment of choice with 2-10% recurrence rate 1, 2, 4
• Conservative measures are inadequate for this grade 1

Critical Pitfalls to Avoid

• Never attribute rectal bleeding or anemia to hemorrhoids without adequate colon evaluation—hemorrhoids alone do not cause positive stool guaiac tests, and colonoscopy should be performed to rule out proximal colonic pathology 1, 2
• Anemia from hemorrhoidal bleeding is rare (0.5 patients/100,000 population) and warrants colonoscopy 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
• Never use corticosteroid creams for more than 7 days due to risk of perianal tissue thinning 1, 2, 3
• Avoid rubber band ligation in immunocompromised patients due to risk of necrotizing pelvic sepsis 1
• 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

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 (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

• Active bleeding with anemia requires definitive surgical intervention—hemorrhoidectomy is indicated as conservative management and office procedures are inadequate 1
• Blood transfusion may be needed preoperatively if hemodynamically unstable 1
• Colonoscopy must be performed to rule out other sources of bleeding 1