What are the guidelines for the medical and surgical treatment of hemorrhoids?

Medical and Surgical Treatment of Hemorrhoids

First-Line Conservative Management for All Grades

All hemorrhoid grades should initially receive conservative management with dietary and lifestyle modifications before considering procedural interventions. 1

Dietary Modifications

• Increase fiber intake to 25-30 grams daily through diet or bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1
• Adequate water intake is essential to complement fiber supplementation and ease bowel movements 1
• Avoid prolonged straining during defecation, which exacerbates hemorrhoidal symptoms 1

Topical Pharmacological Management

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate for symptomatic external and thrombosed hemorrhoids, compared to only 45.8% with lidocaine alone 1
• This combination works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Corticosteroid creams may reduce perianal inflammation but MUST be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1
• Topical nitrates show efficacy but are limited by high incidence of headache (up to 50%) 1

Systemic Pharmacological Options

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1

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Office-Based Procedures for Grade I-III Internal Hemorrhoids

When conservative management fails after 1-2 weeks, rubber band ligation is the first-line procedural intervention for persistent grade I-III internal hemorrhoids. 1

Rubber Band Ligation (Preferred)

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and follow-up duration 1
• More effective than sclerotherapy and requires fewer repeat 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 limiting to 1-2 columns per session is common practice 1
• Pain is the most common complication (5-60%), 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 sepsis 1

Alternative Office Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, achieving 70-85% short-term efficacy but only one-third achieve long-term remission 1, 2
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1, 2
• Bipolar diathermy achieves 88-100% success for bleeding control in grade II hemorrhoids 1

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Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for: 1

• 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 Techniques

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard with recurrence rates of only 2-10% 1, 2
• Ferguson (closed) technique involves primary wound closure and is associated with reduced postoperative pain and faster healing compared to Milligan-Morgan (open) technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Stapled hemorrhoidopexy shows reduced postoperative pain and faster recovery but higher recurrence rates 3
• Hemorrhoidal artery ligation (HAL/RAR) demonstrates better tolerance but higher recurrence compared to excisional techniques 3

Procedures to Avoid

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

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Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours: 1, 2

• Surgical excision under local anesthesia is recommended, providing faster pain relief and reduced recurrence risk
• Complete excision is superior to simple incision and drainage 4

For presentation beyond 72 hours: 1, 4

• Conservative management is preferred as natural resolution has begun
• Treatment includes stool softeners, oral analgesics (acetaminophen or ibuprofen), and topical 0.3% nifedipine with 1.5% lidocaine ointment
• NEVER perform simple incision and drainage as this leads to persistent bleeding and higher recurrence rates 1, 4

Management of Ruptured Thrombosed Hemorrhoid

• Clean area gently with warm water and mild soap 4
• Apply direct pressure if actively bleeding 4
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 4
• Surgical excision is generally unnecessary as natural drainage has occurred 4

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Special Population: Pregnancy

Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in the third trimester. 5

Safe Treatment Options

• Increased dietary fiber (30 g/day) and adequate fluid intake are first-line 5
• Bulk-forming agents like psyllium husk are safe due to lack of systemic absorption 5
• Osmotic laxatives (polyethylene glycol or lactulose) can be safely used 5
• Hydrocortisone foam is safe in the third trimester with no adverse events in prospective study of 204 patients 5
• Avoid stimulant laxatives due to conflicting safety data 5

Surgical Considerations in Pregnancy

• For thrombosed hemorrhoids within 72 hours: surgical excision under local anesthesia provides faster resolution 5
• Approximately 0.2% of pregnant women require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids 5
• Fourth-degree hemorrhoids (irreducible, incarcerated, thrombosed) require surgical intervention 5

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Critical Diagnostic Pitfalls

When to Investigate Further

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until colon is adequately evaluated 1
• Anemia from hemorrhoids is rare (0.5 patients/100,000 population)—always investigate other causes 1
• Anal pain is NOT typical of uncomplicated hemorrhoids—its presence suggests anal fissure (occurs in 20% of hemorrhoid patients), abscess, or thrombosis 1
• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1, 4
• Colonoscopy is indicated for adults >50 years or those with atypical bleeding patterns to exclude colorectal cancer 1, 6

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Grading System for Internal Hemorrhoids

Internal hemorrhoids are classified into four grades: 1

• Grade I: Bleeding but not protruding
• Grade II: Prolapse beyond anus with spontaneous reduction
• Grade III: Prolapse requiring manual reduction
• Grade IV: Irreducible prolapse

This grading guides treatment selection, with grades I-III amenable to office procedures and grades III-IV often requiring surgical intervention.