What are the treatment options for hemorrhoids?

Treatment Options for Hemorrhoids

All hemorrhoids should initially be managed with conservative measures including increased dietary fiber (25-30 grams daily), adequate water intake, and avoidance of straining during defecation, regardless of grade or severity. 1, 2

Conservative Management (First-Line for All Grades)

Dietary and lifestyle modifications form the foundation of hemorrhoid treatment and should be implemented before any procedural intervention. 1, 2

• Increase fiber intake to 25-30 grams daily using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1, 2
• Adequate fluid intake is essential to complement fiber supplementation 1, 2
• Avoid prolonged straining during defecation and limit time on toilet 1, 2
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1

Pharmacological Adjuncts

Phlebotonics (flavonoids like Daflon 500 mg) relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation. 1, 3

• Topical analgesics (lidocaine) provide symptomatic relief of local pain and itching, though long-term efficacy data are limited 1
• Short-term topical corticosteroids (≤7 days only) may reduce perianal inflammation but must never exceed 7 days to avoid thinning of perianal and anal mucosa 1, 2
• Over-the-counter suppositories lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

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

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention when conservative management fails, with success rates of 70-89%. 1, 2, 3

Rubber Band Ligation

• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Bands 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 limit to 1-2 columns 1
• Pain (5-60% of patients) is the most common complication, typically manageable with sitz baths and over-the-counter analgesics 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic infection 1

Alternative Office Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, with 70-85% short-term success 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, 4
• Bipolar diathermy achieves 88-100% bleeding control in grade II hemorrhoids 1

Surgical Management

Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan 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, 2, 3

Indications for Hemorrhoidectomy

• Failure of conservative and office-based treatments 1, 2
• Grade III-IV internal hemorrhoids 1, 2, 3
• Mixed internal and external hemorrhoids 1, 2
• Anemia from hemorrhoidal bleeding 1
• Concomitant conditions requiring surgery (fissure, fistula) 1

Surgical Outcomes

• Lowest recurrence rate of 2-10% 1, 2, 3
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Ferguson (closed) technique may have reduced postoperative pain compared to Milligan-Morgan (open) technique 1

Procedures to Avoid

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

Management of Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management. 1, 2, 3

Early Presentation (Within 72 Hours)

• Complete excision under local anesthesia as outpatient procedure is preferred 1, 2, 3
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1, 2

Late Presentation (>72 Hours)

Conservative management is preferred when symptoms have been present for more than 72 hours, as the natural resolution process has begun. 1, 2, 3

• Stool softeners to prevent straining 1, 2
• Oral analgesics (acetaminophen or ibuprofen) 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone 1, 2
• Topical corticosteroids for ≤7 days only 1, 2
• Topical nitrates show good results but are limited by high incidence of headache 1

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to exclude proximal colonic pathology 1, 2
• Never use corticosteroid preparations for more than 7 days due to risk of perianal tissue thinning 1, 2
• Anal pain is generally not associated with uncomplicated hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in up to 20% of hemorrhoid patients), abscess, or thrombosis 1
• Anemia from hemorrhoids is rare (0.5 patients per 100,000 population)—always investigate other causes 1

When to Reassess or Escalate Care

• If symptoms worsen or fail to improve within 1-2 weeks of treatment, further evaluation is necessary 1, 2
• Significant bleeding, severe pain, or fever requires emergency evaluation to exclude necrotizing pelvic sepsis 1
• Colonoscopy should be performed if bleeding is atypical, no source is evident on anorectal examination, or patient has significant risk factors for colonic neoplasia 1, 2