What are the management options for hemorrhoids?

Management of Hemorrhoids

First-Line Conservative Management for All Grades

All hemorrhoid grades should initially be managed conservatively with dietary and lifestyle modifications, regardless of severity. 1

Dietary and Lifestyle Modifications

• Increase dietary fiber intake to 25-30g daily, with bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to produce soft, bulky stools and reduce straining 1
• Increase water intake to at least 8 glasses daily to soften stool 1
• Avoid prolonged straining during defecation, which exacerbates hemorrhoidal symptoms 1
• Regular sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1

Topical Pharmacological Management

• 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
• This combination works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Short-term topical corticosteroids (≤7 days only) may reduce perianal inflammation, but never exceed 7 days due to risk of perianal tissue thinning 1
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1

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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 for persistent grade I-III internal hemorrhoids. 1

Rubber Band Ligation

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and follow-up duration 1
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Can treat up to 3 hemorrhoids in a single session, though many practitioners limit to 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients), typically minor and 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 first and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage 1
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

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Surgical Management for Grade III-IV Hemorrhoids

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and hemorrhoids causing anemia. 1

Indications for Surgery

• Failure of conservative and office-based treatments 1
• Symptomatic grade III or IV hemorrhoids 1
• Mixed internal and external hemorrhoids 1
• Concomitant conditions (fissure, fistula) requiring surgery 1
• Anemia from hemorrhoidal bleeding represents a critical threshold demanding definitive surgical intervention 1

Surgical Techniques

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard with recurrence rates of only 2-10% 1
• Ferguson (closed) technique involves primary wound closure and is associated with reduced postoperative pain and faster 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 alternatives with varying success and recurrence rates 1

Procedures to Avoid

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

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Management of Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours, complete excision under local anesthesia provides faster pain relief and reduces recurrence risk. 1

Early Presentation (Within 72 Hours)

• Complete excision under local anesthesia as an outpatient procedure is superior to conservative management 1, 2
• Provides faster symptom resolution and lower recurrence rates compared to conservative management 1
• Never perform simple incision and drainage as this leads to persistent bleeding and significantly higher recurrence rates 1, 2

Late Presentation (>72 Hours)

• Conservative management is preferred when natural resolution has begun 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks shows 92% resolution rate 1
• Stool softeners, oral and topical analgesics for symptom control 1
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 1, 2

Management of Ruptured Thrombosed Hemorrhoid

• Clean the area gently with warm water and mild soap 2
• Apply direct pressure if active bleeding is present 2
• Surgical excision is generally not necessary for a thrombosed hemorrhoid that has already ruptured, as natural drainage has occurred 2
• Continue conservative management with topical nifedipine/lidocaine and dietary modifications 2

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Special Populations and Considerations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely during pregnancy 1
• Hydrocortisone foam can be used safely in third trimester with no adverse events compared to placebo 1

Hemorrhoids with Anemia

• Never attribute anemia to hemorrhoids without proper evaluation - colonoscopy should be performed to rule out proximal colonic pathology 1
• Active bleeding on anoscopy with low hemoglobin indicates substantial chronic blood loss requiring definitive control 1
• Hemorrhoidectomy is recommended for patients with anemia from hemorrhoidal bleeding 1
• Blood transfusion may be needed given low hemoglobin levels, and preoperative optimization should be considered if hemodynamically stable 1

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Critical Diagnostic Considerations

When to Investigate Further

• 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 due to hemorrhoidal disease 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 patients with hemorrhoids), abscess, or thrombosis 1
• Complete colonic evaluation by colonoscopy is indicated when bleeding is atypical, no source is evident on anorectal examination, or patient has significant risk factors for colonic neoplasia 1

Physical Examination

• Perform focused medical history and complete physical examination, including digital rectal examination 2, 3
• Anoscopy should be performed when feasible and well tolerated to properly visualize hemorrhoids 1, 3
• Colonoscopy should be performed only if there is concern for inflammatory bowel disease or cancer based on patient history or examination 3

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Common Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days as prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1
• Never perform simple incision and drainage of thrombosed external hemorrhoids - this leads to persistent bleeding and higher recurrence rates 1, 2
• Do not delay definitive treatment when active bleeding has caused anemia - the natural history will be continued blood loss 1
• Avoid assuming all anorectal symptoms are due to hemorrhoids - other conditions like anal fissures, abscesses, or fistulas may coexist or be the primary cause 1
• Rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids 2, 3
• Monitor immunocompromised patients closely as they are at increased risk for severe infection and complications 2