What are the treatment options for external hemorrhoids?

Treatment of External Hemorrhoids

First-Line Conservative Management

All external hemorrhoids should initially be managed with dietary and lifestyle modifications, including increased fiber (25-30 grams daily) and water intake to soften stool and reduce straining during defecation. 1

• Avoid straining during bowel movements, as this exacerbates symptoms 1
• Stool softeners should be used to facilitate easier defecation 1, 2
• This conservative approach is recommended regardless of symptom severity as initial therapy 1

Topical Pharmacological Treatment

For Non-Thrombosed External Hemorrhoids

Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks is the most effective topical treatment, achieving 92% resolution compared to 45.8% with lidocaine alone. 1

• This combination works by relaxing internal anal sphincter hypertonicity that contributes to pain 1
• No systemic side effects have been observed with topical nifedipine 1
• Lidocaine provides symptomatic relief of local pain and itching 1

Alternative Topical Agents

• Topical corticosteroid creams may reduce local perianal inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1
• Topical nitrates show good results but are 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

Over-the-counter analgesics (acetaminophen or ibuprofen) should be used for additional pain control 1

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours of symptom onset: Complete surgical excision under local anesthesia as an outpatient procedure is recommended, providing faster pain relief and lower recurrence rates. 1, 2

• Excision achieves symptom resolution in shorter duration compared to conservative management 1
• This can be safely performed with low complication rates 1
• Never perform simple incision and drainage alone—this leads to persistent bleeding and significantly higher recurrence rates 1

For presentation beyond 72 hours: Conservative management is preferred, as the natural resolution process has begun. 1, 2

• Treatment includes stool softeners, oral and topical analgesics (5% lidocaine), and topical 0.3% nifedipine with 1.5% lidocaine ointment 1, 2
• Topical muscle relaxants can provide additional pain relief, particularly with severe sphincter spasm 1
• Corticosteroid creams may be applied for ≤7 days only 1

Emerging Treatment Option

Recent evidence suggests rubber band ligation combined with local anesthesia injection may be an alternative to hemorrhoidectomy for symptomatic non-thrombosed external hemorrhoids. 3

• In a cohort of 50 patients, 50% reported no post-procedure discomfort, 44% had mild pain managed with OTC analgesics 3
• Approximately 90% were satisfied with the technique 3
• Lidocaine is injected into surrounding tissue to anesthetize the hemorrhoid prior to band application 3
• This represents a departure from traditional teaching that rubber band ligation should not be used for external hemorrhoids due to pain concerns 3

Surgical Hemorrhoidectomy

Surgical excision is indicated for mixed internal and external hemorrhoids, failure of conservative and topical therapies, or when concomitant conditions (fissure, fistula) require surgery. 1

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) has low recurrence rates of 2-10% 1, 2
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Both open and closed techniques show comparable efficacy with no consistent difference in postoperative pain 4

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days—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 1
• Avoid anal dilatation entirely—52% incontinence rate at 17-year follow-up and causes sphincter injuries 1, 4
• Avoid cryotherapy—rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Red Flags Requiring Emergency Evaluation

The clinical triad of severe pain, high fever, and urinary retention suggests necrotizing pelvic sepsis, a rare but serious complication requiring emergency intervention. 1, 5

• Immunocompromised patients (uncontrolled diabetes, AIDS, neutropenia) have increased risk of complications 1, 5
• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding or fever, further evaluation is necessary 1

Important Diagnostic Considerations

• External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1
• Anal pain with uncomplicated external hemorrhoids suggests other pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids) 1
• Anoscopy should be performed when feasible to rule out other causes of anorectal symptoms 1