What is the best treatment for hemorrhoids?

Treatment of Hemorrhoids

The best treatment for hemorrhoids begins with conservative management (increased fiber, water intake, and avoiding straining) for all patients, followed by rubber band ligation for persistent grade I-III internal hemorrhoids, and surgical hemorrhoidectomy for grade III-IV disease or when conservative and office-based treatments fail. 1

Initial Conservative Management (First-Line for All Hemorrhoids)

All hemorrhoid grades should start with dietary and lifestyle modifications before considering procedural interventions 1:

• Increase dietary fiber to 25-30g daily and water intake (at least 1.5-2L daily) to soften stool and reduce straining 1
• Avoid prolonged straining during defecation, which is the primary modifiable risk factor 1
• Take regular sitz baths (warm water soaks for 10-15 minutes, 2-3 times daily) to reduce inflammation and discomfort 1

Pharmacological Adjuncts to Conservative Management

• Flavonoids (phlebotonics) improve venous tone and control bleeding in all hemorrhoid grades, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Topical analgesics (lidocaine 5%) provide symptomatic relief of local pain and itching, though long-term efficacy data are limited 1, 3
• Short-term topical corticosteroids (≤7 days only) may reduce perianal inflammation, but must be strictly limited to avoid thinning of perianal and anal mucosa 1, 3

Critical Pitfall: Never use corticosteroid creams for more than 7 days, as prolonged use causes tissue thinning and increases injury risk 1

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

When conservative management fails after 1-2 weeks, proceed to office-based interventions 1:

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids 1:

• Success rates: 70.5-89% depending on hemorrhoid grade and follow-up duration 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can treat up to 3 hemorrhoid columns per session, though many practitioners limit to 1-2 columns at a time 1
• Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1

Complications: Pain (5-60%, usually minor and manageable with sitz baths and OTC analgesics), bleeding when eschar sloughs (1-2 weeks post-procedure), and rarely necrotizing pelvic sepsis in immunocompromised patients 1

Contraindication: Avoid in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1

Alternative Office Procedures (When Rubber Band Ligation Fails or Is Contraindicated)

• Injection sclerotherapy: Suitable for grade I-II hemorrhoids, 70-85% short-term success but only one-third achieve long-term remission 1, 2
• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids, but requires more repeat treatments 1, 2
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for 1:

• Failure of conservative and office-based therapies
• Symptomatic grade III-IV hemorrhoids
• Mixed internal and external hemorrhoids
• Hemorrhoids causing anemia from chronic bleeding
• Concomitant conditions requiring surgery (fissure, fistula)

Surgical Techniques

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard with the lowest recurrence rate (2-10%) 1, 2:

• Ferguson (closed) technique: Wounds closed primarily, associated with reduced postoperative pain and faster healing 1
• Milligan-Morgan (open) technique: Wounds left open, no significant outcome difference 1

Major drawback: Postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks 1

Procedures to Avoid:

• Never perform anal dilatation: 52% incontinence rate at 17-year follow-up 1
• Avoid cryotherapy: 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 reduced recurrence risk 1, 2

Critical Pitfall: Never perform simple incision and drainage of the thrombus alone—this leads to persistent bleeding and higher recurrence rates 1

Late Presentation (>72 Hours)

Conservative management is preferred for presentation beyond 72 hours 1:

• Stool softeners
• Oral analgesics (acetaminophen or ibuprofen)
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks achieves 92% resolution rate (vs. 45.8% with lidocaine alone) 1
• No systemic side effects observed with topical nifedipine 1

Alternative topical agents:

• Topical nitrates show good results but limited by high incidence of headache (up to 50%) 1, 3
• Topical heparin significantly improves healing, though evidence is limited 1, 3

Special Considerations

When to Suspect Complications Requiring Emergency Evaluation

Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis—a rare but serious complication requiring emergency evaluation 1

Diagnostic Pitfalls

• 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
• Anemia from hemorrhoids is rare (0.5 patients/100,000 population)—always 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 hemorrhoid patients) 1
• Colonoscopy is mandatory for patients at risk of colorectal cancer (age >50 years) even if hemorrhoids are visualized 1, 4

Hemorrhoids in Pregnancy

Safe treatments during pregnancy include 1:

• Dietary fiber and adequate fluid intake
• Bulk-forming agents (psyllium husk 5-6 teaspoonfuls with 600 mL water daily)
• Osmotic laxatives (polyethylene glycol or lactulose)
• Hydrocortisone foam in third trimester (no adverse events vs. placebo in prospective study of 204 patients)