What are the treatment options for external hemorrhoids?

Treatment of External Hemorrhoids

For non-thrombosed external hemorrhoids, start with topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks, which achieves 92% resolution compared to 45.8% with lidocaine alone. 1

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

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

• Increase dietary fiber to 25-30 grams daily and water intake to soften stool and reduce straining 1
• Avoid straining during defecation to prevent symptom exacerbation 1
• Sitz baths (warm water soaks) 3-4 times daily to reduce inflammation and discomfort 1
• Stool softeners to prevent constipation and straining 1

Topical Pharmacological Treatment for Symptomatic External Hemorrhoids

Most Effective Option

Topical 0.3% nifedipine with 1.5% lidocaine ointment is the most effective topical treatment: 1, 2

• Apply every 12 hours for two weeks 1, 2
• Works by relaxing internal anal sphincter hypertonicity that contributes to pain 1
• No systemic side effects observed 1, 2
• Achieves 92% resolution rate versus 45.8% with lidocaine alone 1, 2

Alternative Topical Agents

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

  • Provides symptomatic relief of local pain and itching 1
  • Wash hands with soap and water after application 3
  • Do not use for more than one week without consulting a doctor 3

• Topical corticosteroids: May reduce local perianal inflammation 1

  • CRITICAL LIMITATION: Use for ≤7 days ONLY to avoid thinning of perianal and anal mucosa 1
  • Long-term use is potentially harmful 1

• Topical nitrates: Show good results for pain relief 1

  • Major limitation: High incidence of headache (up to 50%) may limit use 1

• Topical heparin: Significantly improves healing 1

  • Limited evidence from small studies 1

Oral Analgesics

• Over-the-counter acetaminophen or ibuprofen for additional pain control 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 as an outpatient procedure: 1, 4

• Provides faster pain relief and lower recurrence rates compared to conservative management 1, 4
• Can be safely performed with low complication rates 1
• Superior to simple incision and drainage, which leads to persistent bleeding and higher recurrence 1

Late Presentation (>72 Hours After Onset)

Conservative management is preferred when natural resolution has begun: 1, 4

• Stool softeners 1, 4
• Oral analgesics (acetaminophen or NSAIDs) 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1
• Topical analgesics such as 5% lidocaine 1, 4
• Sitz baths 3-4 times daily 1
• Short-term topical corticosteroids (≤7 days only) if significant inflammation present 1

Emerging Treatment Option: Rubber Band Ligation for External Hemorrhoids

Recent evidence suggests rubber band ligation combined with local anesthesia injection may be an alternative to hemorrhoidectomy for symptomatic non-thrombosed external hemorrhoids: 5

• Lidocaine injected into surrounding tissue prior to band application 5
• In a cohort of 50 patients: 50% reported no post-procedure discomfort, 44% had mild pain managed with OTC analgesics 5
• ~90% patient satisfaction rate 5
• This represents a newer approach not yet incorporated into major guidelines, but shows promise 5

When to Consider Surgical Hemorrhoidectomy

Surgical excision is indicated for: 1

• Failure of medical and conservative therapy 1
• Mixed internal and external hemorrhoids 1
• Symptomatic external hemorrhoids unresponsive to topical treatments 1
• Recurrence rate of only 2-10% with conventional excisional hemorrhoidectomy 1

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
• NEVER use corticosteroid creams for >7 days—prolonged use causes thinning of perianal and anal mucosa, increasing injury risk 1
• Do not apply lidocaine on large areas, cut/irritated skin, or for >1 week without consulting a doctor 3
• Avoid bandaging or applying local heat (heating pads) when using topical lidocaine 3

Red Flags Requiring Emergency Evaluation

Patients should return immediately for: 1

• Severe pain with high fever and urinary retention—suggests necrotizing pelvic sepsis (rare but catastrophic) 1
• Significant bleeding causing hemodynamic instability 1
• Symptoms worsening or failing to improve within 1-2 weeks 1

Special Population: Pregnancy

For pregnant patients with external hemorrhoids: 1

• Dietary fiber and adequate fluid intake are safe 1
• Bulk-forming agents like psyllium husk are safe 1
• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely 1
• Hydrocortisone foam can be used safely in third trimester 1