What is the recommended treatment for hemorrhoids?

Recommended Treatment for Hemorrhoids

Start with conservative management (increased fiber, water intake, and avoidance of straining) for all hemorrhoid grades, then escalate to rubber band ligation for persistent grade I-III internal hemorrhoids, and reserve surgical hemorrhoidectomy for grade III-IV disease unresponsive to less invasive approaches or when complications occur. 1, 2, 3

Initial Conservative Management (First-Line for All Grades)

All patients with hemorrhoids should begin with dietary and lifestyle modifications regardless of grade or type 1, 2:

• Increase dietary fiber to 25-30 grams daily, preferably using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1, 2
• Increase water intake to maintain soft, bulky stools 1, 2
• Avoid prolonged straining during defecation and limit time on toilet 1
• Consider phlebotonics (flavonoids) to relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3

Topical Treatments for Symptom Relief

• Topical analgesics (lidocaine 5%) provide symptomatic relief of local pain and itching 1
• Short-term topical corticosteroids (≤7 days only) may reduce perianal inflammation, but must be limited to avoid thinning of perianal and anal mucosa 1, 4, 2
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for 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, 4

Office-Based Procedures (For Persistent Grade I-III Internal Hemorrhoids)

When conservative management fails after 1-2 weeks, proceed to office-based interventions 1:

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids 1, 3:

• Success rates: 70.5-89% depending on hemorrhoid grade and follow-up duration 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can be performed in office without anesthesia 1
• Band must be placed at least 2 cm proximal to dentate line to avoid severe pain 1
• Up to 3 hemorrhoids can be banded per session, though many practitioners limit to 1-2 columns 1

Complications: Pain (5-60%, usually minor), bleeding when eschar sloughs (1-2 weeks post-procedure), abscess, urinary retention, and rarely necrotizing pelvic sepsis (especially in immunocompromised patients) 1

Contraindication: Avoid in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1

Alternative Office Procedures (Less Effective)

• Injection sclerotherapy: Suitable for grade I-II hemorrhoids only, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 3
• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids, but requires more repeat treatments 1, 3
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

Surgical Management (For Grade III-IV or Failed Conservative/Office Therapy)

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for: 1, 2, 3

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

Surgical Technique

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard with recurrence rates of only 2-10% 1, 2, 3:

• Ferguson (closed) technique involves primary wound closure and is associated with reduced postoperative pain and faster healing compared to Milligan-Morgan (open) 1
• Major drawback: Postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Success rate approaches 90-98% for grade III-IV disease 1

Procedures to Avoid:

• Never perform anal dilatation—52% incontinence rate at 17-year follow-up 1, 5
• Avoid cryotherapy—causes prolonged pain, foul-smelling discharge, and requires more additional therapy 1

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

Within 72 hours of symptom onset: 1, 4, 2, 3

• Surgical excision under local anesthesia is preferred for faster symptom resolution and lower recurrence rates
• Can be performed as outpatient procedure with low complication rates
• Never perform simple incision and drainage—leads to persistent bleeding and higher recurrence 1, 4

Beyond 72 hours of symptom onset: 1, 4, 3

• Conservative management is preferred as natural resolution has begun
• Stool softeners, oral and topical analgesics
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks achieves 92% resolution rate (vs. 45.8% with lidocaine alone) 1, 4, 2
• No systemic side effects with topical nifedipine 1

Alternative Topical Agents for Thrombosed Hemorrhoids

• Topical nitrates: Good results but limited by high incidence of headache (up to 50%) 1, 4
• Topical heparin: Significantly improves healing, though evidence limited to small studies 1, 4

Special Populations

Pregnancy

• Safe treatments: Dietary fiber, adequate fluids, bulk-forming agents (psyllium husk), osmotic laxatives (polyethylene glycol, lactulose) 1
• Hydrocortisone foam can be used safely in third trimester with no adverse events 1

Patients with Anemia

• Hemorrhoidectomy is indicated when anemia results from hemorrhoidal bleeding, as this represents substantial chronic blood loss requiring definitive control 1
• Never attribute anemia to hemorrhoids without proper evaluation—perform colonoscopy to rule out proximal colonic pathology 1
• Consider blood transfusion preoperatively if hemodynamically unstable or hemoglobin critically low 1

Critical Diagnostic Considerations

Before attributing symptoms to hemorrhoids: 1, 2

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood requires adequate colonic evaluation 1
• Anal pain is generally NOT associated with uncomplicated hemorrhoids—suggests anal fissure (occurs in 20% of hemorrhoid patients), abscess, or thrombosis 1
• Anemia from hemorrhoids is rare (0.5 patients/100,000 population) 1
• Perform colonoscopy if bleeding is atypical, no source evident on anorectal exam, or significant risk factors for colonic neoplasia 1

When to Reassess

Seek further evaluation if: 1, 4

• Symptoms worsen or fail to improve within 1-2 weeks
• Significant bleeding, severe pain, or fever develops
• Severe pain with high fever and urinary retention (suggests necrotizing pelvic sepsis—requires emergency evaluation) 1