What is the treatment for external hemorrhoids?

Treatment for External Hemorrhoids

For non-thrombosed external hemorrhoids, start with conservative management including increased fiber/water intake and topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks, which achieves 92% resolution. 1

Initial Conservative Management (First-Line for All External Hemorrhoids)

All external hemorrhoids should begin with conservative therapy before considering procedural interventions: 1

• Increase dietary fiber and water intake to soften stool and reduce straining during defecation 1
• Avoid straining during bowel movements, as this is the primary precipitating factor 1
• Warm sitz baths to reduce inflammation and discomfort 1
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for pain control 2

Topical Pharmacological Treatment for Symptomatic External Hemorrhoids

When conservative measures alone are insufficient, add topical therapy:

Most Effective Option

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks 1, 3
  • Achieves 92% resolution rate compared to only 45.8% with lidocaine alone 1, 3
  • Works by relaxing internal anal sphincter hypertonicity that contributes to pain 1
  • No systemic side effects observed 1, 3
  • Lidocaine component provides symptomatic relief of local pain and itching 1

Alternative Topical Agents

• Topical lidocaine 5% (FDA-approved): Apply to affected area not more than 3-4 times daily 4

  • Do not use for more than one week without consulting a doctor 4
  • Avoid contact with eyes and mucous membranes 4

• Topical corticosteroid creams may reduce local perianal inflammation 1

  • Critical limitation: Use for NO MORE than 7 days to avoid thinning of perianal and anal mucosa 1, 2
  • Long-term use increases risk of tissue injury 1

• Topical nitrates show good results for pain relief 1

  • Limited by high incidence of headache (up to 50% of patients) 1

• Topical heparin significantly improves healing, though evidence is limited to small studies 1

Management of Thrombosed External Hemorrhoids

The treatment approach depends critically on timing of presentation:

Early Presentation (Within 72 Hours of Onset)

• Complete surgical excision under local anesthesia is recommended 1, 5
  • Provides faster pain relief and reduces risk of recurrence 1
  • Can be performed safely as an outpatient procedure 1
  • Superior to simple incision and drainage, which leads to persistent bleeding and higher recurrence rates 1, 5

Late Presentation (>72 Hours After Onset)

• Conservative management is preferred once the natural resolution process has begun 1, 5
  • Stool softeners 1, 5
  • Oral analgesics (acetaminophen or ibuprofen) 2
  • Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1
  • Topical analgesics such as 5% lidocaine 4
  • The condition is usually self-limiting and subsides in a few days to a week 6

When to Consider Surgical Hemorrhoidectomy

Surgical intervention is indicated for: 1

• Failure of conservative and topical medical therapy
• Mixed internal and external hemorrhoids requiring definitive treatment
• Concomitant conditions (fissure, fistula) requiring surgery
• Recurrent thrombosis despite conservative management

Conventional excisional hemorrhoidectomy has a low recurrence rate of 2-10% but requires narcotic analgesics postoperatively, with most patients not returning to work for 2-4 weeks 1, 7

Critical Pitfalls to Avoid

• Never perform simple incision and drainage of thrombosed external hemorrhoids—this leads to persistent bleeding and significantly higher recurrence rates 1, 5
• Never use corticosteroid creams for more than 7 days—prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 2
• Do not attribute significant bleeding or anemia to external hemorrhoids alone—ensure proper evaluation to rule out other pathology 1
• Avoid anal dilatation—associated with 52% incontinence rate at 17-year follow-up 1, 7
• Avoid cryotherapy—causes prolonged pain, foul-smelling discharge, and requires more additional therapy 1, 7

Special Populations

Pregnant Patients

• 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 1
• Hydrocortisone foam can be used safely in the third trimester 1

Immunocompromised Patients

• Have increased risk of necrotizing pelvic infection from any hemorrhoid procedure 1, 2
• The clinical triad of severe pain, high fever, and urinary retention suggests necrotizing pelvic sepsis requiring emergency intervention 2