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 water intake, 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 modifications form the foundation of treatment: increase fiber intake to produce soft, bulky stools and reduce straining 1, 2
• Psyllium husk at 5-6 teaspoonfuls with 600 mL water daily is specifically recommended by the American Gastroenterological Association 1
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1
• Phlebotonics (flavonoids) such as Daflon 500 mg relieve symptoms including bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3, 4

Important Caveat

Stop fiber supplementation and seek medical evaluation if constipation lasts more than 7 days, rectal bleeding occurs, or you fail to have a bowel movement, as these may indicate serious conditions 5

Topical Pharmacological Management

For Symptomatic or Thrombosed External Hemorrhoids

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective, achieving 92% resolution rate compared to 45.8% with lidocaine alone 1, 2
• This works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Topical corticosteroids may reduce perianal inflammation but MUST be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1, 2
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) provide additional pain control 1

Critical Pitfall

Never use corticosteroid creams for more than 7 days—prolonged use causes tissue thinning and increases injury risk 1, 2

Office-Based Procedures (For Persistent 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% to 89% depending on hemorrhoid grade 1, 2, 4

Rubber Band Ligation Details

• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• Can treat up to 3 hemorrhoids per session, though many practitioners limit to 1-2 columns 1
• Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Pain is the most common complication (5-60% of patients) but typically manageable with sitz baths and over-the-counter analgesics 1
• Repeated banding needed in up to 20% of patients 4

Alternative Office Procedures

• Injection sclerotherapy: suitable for first and second-degree hemorrhoids, 70-85% short-term efficacy but only one-third achieve long-term remission 1, 4
• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids, 70-80% success in reducing bleeding and prolapse, but requires more repeat treatments 1, 4
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for:

• Failure of medical and office-based therapy 1, 2
• Symptomatic grade III or IV hemorrhoids 1, 2
• Mixed internal and external hemorrhoids 1, 2
• Anemia from hemorrhoidal bleeding 1
• Concomitant conditions (fissure, fistula) requiring surgery 1

Surgical Approach

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall with lowest recurrence rate of 2-10% 1, 2, 4
• No significant difference in outcomes between open and closed techniques 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Success rate approaches 90-98% for complicated disease 1

Procedures to Avoid

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

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

If presenting within 72 hours of symptom onset:

• Complete excision under local anesthesia is recommended as outpatient procedure 1, 2, 4
• Provides faster pain relief and reduces recurrence risk compared to conservative management 1, 2
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1, 2

If presenting >72 hours after onset:

• Conservative management is preferred as natural resolution has begun 1, 2, 4
• Treatment includes stool softeners, oral and topical analgesics (5% lidocaine), sitz baths 1, 4
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 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 fluids, and psyllium husk 1
• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely 1
• Hydrocortisone foam is safe in third trimester with no adverse events 1

Patients with Anemia

• Hemorrhoidectomy is indicated when anemia results from hemorrhoidal bleeding, as this represents a critical threshold demanding definitive surgical intervention 1
• Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1
• Blood transfusion may be needed preoperatively if hemodynamically unstable 1

Critical Diagnostic Considerations

When to Perform Colonoscopy

• Hemorrhoids alone do not cause positive stool guaiac tests 1
• Fecal occult blood should not be attributed to hemorrhoids until colon is adequately evaluated 1, 2
• Colonoscopy indicated if concern for inflammatory bowel disease or cancer based on history or examination 1, 2, 3
• Adults older than 50 years with rectal bleeding should undergo colonoscopy even if hemorrhoids are seen 6
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) 1

Red Flags

• 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), abscess, or thrombosis 1
• If symptoms worsen or fail to improve within 1-2 weeks, significant bleeding occurs, or fever develops, further evaluation is necessary 1, 3

Treatment Algorithm Summary

1. All patients: Start with fiber (psyllium 5-6 teaspoonfuls with 600 mL water daily), increased water intake, avoid straining 1, 2
2. Symptomatic relief: Add flavonoids (Daflon 500 mg) for bleeding/pain/swelling 1, 3, 4
3. External/thrombosed hemorrhoids: Topical 0.3% nifedipine + 1.5% lidocaine every 12 hours for 2 weeks 1, 2
4. Persistent grade I-III internal hemorrhoids: Rubber band ligation (first procedural choice) 1, 2, 4
5. Grade III-IV or failed office procedures: Conventional excisional hemorrhoidectomy 1, 2, 4
6. Thrombosed external <72 hours: Complete excision under local anesthesia 1, 2, 4
7. Thrombosed external >72 hours: Conservative management with topical nifedipine/lidocaine 1, 2, 4