What is the treatment for external hemorrhoids?

Treatment of External Hemorrhoids

First-Line Conservative Management

All external hemorrhoids should initially be managed conservatively with dietary modifications, increased fiber and water intake, and avoidance of straining during defecation. 1, 2

• Increase dietary fiber intake to soften stool and reduce straining 1, 3
• Ensure adequate water intake (typically 6-8 glasses daily) 1
• Avoid prolonged sitting on the toilet and straining during bowel movements 1, 2
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Management for Symptomatic External Hemorrhoids

Most Effective Topical Treatment

Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks is the most effective medical treatment, achieving 92% resolution compared to only 45.8% with lidocaine alone. 1, 2, 4

• Nifedipine works by relaxing internal anal sphincter hypertonicity that contributes to pain 1, 2
• No systemic side effects have been observed with topical nifedipine application 1, 2, 4
• Lidocaine provides immediate symptomatic relief of local pain and itching 1, 2, 5

Alternative Topical Agents (if nifedipine unavailable)

• Topical corticosteroids may reduce local perianal inflammation but MUST be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1, 2, 5
• Topical nitrates show good results for pain relief but are limited by high incidence of headache (up to 50% of patients) 1, 2, 5
• Topical heparin significantly improves healing, though evidence is limited to small studies 1, 2, 5

Oral Medications

• Flavonoids (phlebotonics) relieve symptoms including bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2, 3
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for additional pain control 1

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours of Symptom Onset)

Surgical excision under local anesthesia is recommended for faster pain relief and reduced risk of recurrence. 1, 2, 3

• Complete excision of the thrombosed hemorrhoid can be safely performed as an outpatient procedure 1
• This provides more rapid and persistent symptom relief compared to conservative management 1, 6
• Never perform simple incision and drainage of the thrombus—this leads to persistent bleeding and higher recurrence rates 1, 2

Late Presentation (>72 Hours After Onset)

Conservative management is preferred as the natural resolution process has begun. 1, 2, 3

• Use topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1, 2, 4
• Stool softeners to prevent straining 3
• Oral and topical analgesics (5% lidocaine) 3
• Sitz baths for symptomatic relief 2

Surgical Management for Refractory Cases

Excisional hemorrhoidectomy is indicated for failure of medical therapy, mixed internal and external hemorrhoids, or when concomitant conditions (fissure, fistula) require surgery. 1

• Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) has low recurrence rates of 2-10% 1, 3, 7
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Postoperative pain can be managed with NSAIDs, narcotics, fiber supplements, and topical antispasmodics 7

Novel Treatment Option

Recent evidence suggests rubber band ligation combined with local anesthesia injection may be an alternative to hemorrhoidectomy for symptomatic non-thrombosed external hemorrhoids. 8

• In a cohort of 50 patients, 50% reported no post-procedure discomfort, 44% had mild pain managed with OTC analgesics 8
• Overall ~90% were satisfied with the technique and would opt for the procedure again 8
• This represents a departure from traditional teaching that rubber band ligation should only be used for internal hemorrhoids 8

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days—prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 2, 5
• Never perform simple incision and drainage of thrombosed external hemorrhoids—this leads to persistent bleeding and higher recurrence rates 1, 2
• Do not attribute rectal bleeding to hemorrhoids without proper evaluation—ensure colonoscopy is performed to rule out other pathology if bleeding is atypical or patient has risk factors for colonic neoplasia 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 Considerations

• External hemorrhoids are covered by anoderm and highly innervated by somatic pain receptors, leading to significant pain especially when thrombosed 8
• Unlike internal hemorrhoids, external hemorrhoids typically cause symptoms only when thrombosed 1
• Anoscopy should be performed when feasible and well tolerated to rule out other causes of anorectal symptoms 1, 2