What is the best treatment approach for internal and external hemorrhoids?

Treatment of Internal and External Hemorrhoids

First-Line Conservative Management for All Hemorrhoids

All patients with hemorrhoids—regardless of type or grade—should begin with conservative management including increased dietary fiber (5-6 teaspoonfuls psyllium husk with 600 mL water daily), adequate fluid intake, and avoidance of straining during defecation. 1, 2

• Sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2, 3
• This conservative approach is appropriate for all hemorrhoid grades initially 1

Topical Pharmacological Management

For External Hemorrhoids (Including Thrombosed)

Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution compared to 45.8% with lidocaine alone, with no systemic side effects. 1, 2

• This works by relaxing internal anal sphincter hypertonicity that contributes to pain 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 1, 2
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) provide additional pain control 1

For Internal Hemorrhoids

• Topical analgesics (lidocaine) provide symptomatic relief of pain and itching, though long-term efficacy data are limited 1, 2
• Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

Office-Based Procedures for Internal Hemorrhoids (Grades I-III)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails, with success rates of 70.5-89%. 1, 3

Rubber Band Ligation Details

• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients) but is 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, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 3
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1, 3
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) 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, 3

Hemorrhoidectomy Indications

• Grade III-IV internal hemorrhoids 1
• Failure of conservative and office-based treatments 1
• Mixed internal and external hemorrhoids 1
• Hemorrhoids with anemia from chronic bleeding 1
• Concomitant conditions (fissure, fistula) requiring surgery 1

Surgical Outcomes

• Recurrence rate of only 2-10% 1, 3
• Major drawback is postoperative pain requiring narcotic analgesics 1
• Most patients do not return to work for 2-4 weeks 1
• No significant difference in outcomes between open (Milligan-Morgan) and closed (Ferguson) techniques 1

Procedures to Avoid

• Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up 1, 4
• Cryotherapy should be avoided due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 4

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

For thrombosed external hemorrhoids presenting within 72 hours, complete excision under local anesthesia provides faster pain relief and reduces recurrence risk compared to conservative management. 1, 3

• This can be performed as an outpatient procedure with low complication rates 1
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1, 2
• Multiple counter-incisions are preferred over single long incisions to prevent step-off deformities 5

Late Presentation (>72 Hours)

For presentation >72 hours after onset, conservative management is preferred with stool softeners, oral and topical analgesics (5% lidocaine), and topical nifedipine-lidocaine ointment. 1, 3

• Pain typically resolves spontaneously after 7-10 days 5
• Topical 0.3% nifedipine with 1.5% lidocaine achieves 92% resolution at 14 days 1, 5

Critical Diagnostic Considerations

Hemorrhoids alone do not cause positive stool guaiac tests or anemia—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated. 1

• Anemia from hemorrhoidal disease is rare (0.5 patients/100,000 population) 1
• Anal pain is generally not associated with uncomplicated hemorrhoids—its presence suggests thrombosis, anal fissure (occurs in 20% of hemorrhoid patients), abscess, or other pathology 1, 5
• Colonoscopy should be performed when bleeding is atypical, no source is evident on anorectal examination, or the patient has significant risk factors for colonic neoplasia 1, 6

Treatment Algorithm by Hemorrhoid Grade

Grade I Internal Hemorrhoids

• Conservative management → Rubber band ligation if persistent 1

Grade II-III Internal Hemorrhoids

• Conservative management → Rubber band ligation (first-line procedural) → Hemorrhoidectomy if failed 1, 3

Grade IV Internal Hemorrhoids

• Hemorrhoidectomy is first-line treatment due to low success with office procedures 1, 3

External Hemorrhoids (Non-thrombosed)

• Conservative management with topical nifedipine-lidocaine 1, 2

Thrombosed External Hemorrhoids

• <72 hours: Complete excision under local anesthesia 1, 3

• 72 hours: Conservative management with topical nifedipine-lidocaine 1, 3

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in third trimester 1
• Safe treatments include dietary fiber, adequate fluids, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in third trimester 1

Immunocompromised Patients

• Avoid rubber band ligation due to increased risk of necrotizing pelvic sepsis 1
• Consider earlier surgical intervention if needed 7