What are the recommended management options for hemorrhoids?

Management of Hemorrhoids

All hemorrhoid grades should begin with conservative management including increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining during defecation, with escalation to office-based procedures or surgery based on grade and response to initial therapy. 1

Initial Assessment and Classification

• Perform digital rectal examination and anoscopy when tolerable to classify hemorrhoids and rule out other pathology 1, 2
• Check vital signs, complete blood count, and coagulation parameters if significant bleeding is present 2
• Internal hemorrhoids are graded I-IV: Grade I (bleeding without prolapse), Grade II (prolapse with spontaneous reduction), Grade III (requiring manual reduction), Grade IV (irreducible) 1
• External hemorrhoids cause symptoms primarily when thrombosed, presenting with acute pain and perianal lump 1

Critical pitfall: Never attribute fecal occult blood or anemia to hemorrhoids until colonoscopy excludes proximal colonic pathology—hemorrhoids alone do not cause positive guaiac tests 1. Anal pain suggests other pathology (fissure, abscess, thrombosis) rather than uncomplicated hemorrhoids 1.

Conservative Management (First-Line for All Grades)

• Increase dietary fiber to 25-30g daily using psyllium husk (5-6 teaspoonfuls with 600mL water daily) 1, 2
• Ensure adequate fluid intake to soften stool and reduce straining 1, 2
• Recommend sitz baths (warm water soaks) to reduce inflammation and discomfort 1
• Prescribe 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

For thrombosed external hemorrhoids, topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution compared to 45.8% with lidocaine alone, without systemic side effects. 1, 2

• Apply topical corticosteroids for perianal inflammation for maximum 7 days only to avoid thinning of perianal and anal mucosa 1, 2
• Topical nitrates provide pain relief but are limited by high incidence (up to 50%) of headache 1
• Topical heparin improves healing of acute hemorrhoids, though evidence is limited 1

Critical pitfall: Never use corticosteroid preparations for more than 7 days—prolonged use causes tissue thinning and increased injury risk 1.

Office-Based Procedures (Grades I-III)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails, with success rates of 70.5-89%. 1, 3

Rubber Band Ligation Technique

• Place bands at least 2cm proximal to dentate line to avoid severe pain 1
• Treat 1-2 hemorrhoid columns per session (up to 3 maximum) 1
• Perform in office setting without anesthesia using suction-based devices 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1

Contraindications: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic sepsis 1.

Alternative Office Procedures

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

Procedures to avoid: Anal dilatation causes 52% incontinence rate at 17-year follow-up and should never be performed 1. Cryotherapy causes prolonged pain, foul-smelling discharge, and greater need for additional therapy 1.

Management of Thrombosed External Hemorrhoids

Presentation Within 72 Hours

For thrombosed external hemorrhoids presenting within 72 hours, perform complete excision under local anesthesia as an outpatient procedure—this provides faster pain relief and lower recurrence rates compared to conservative management. 1, 2

• Excision is superior to simple incision and drainage, which causes persistent bleeding and higher recurrence 1
• Can be safely performed in office setting with local anesthesia 1

Presentation Beyond 72 Hours

• Conservative management is preferred once natural resolution has begun 1, 2
• Prescribe stool softeners, oral analgesics (acetaminophen or ibuprofen), and topical 0.3% nifedipine with 1.5% lidocaine 1, 3
• Apply topical corticosteroids for maximum 7 days 1

Critical pitfall: Never perform simple incision and drainage alone—this leads to persistent bleeding and significantly higher recurrence rates 1.

Surgical Management

Indications for Hemorrhoidectomy

Conventional excisional hemorrhoidectomy 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

• Hemorrhoidectomy achieves lowest recurrence rate (2-10%) and 90-98% success rate 1, 3
• Ferguson (closed) technique involves primary wound closure and reduces postoperative pain 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

Specific Surgical Indications

• Grade IV hemorrhoids (irreducible, incarcerated) require surgical intervention 1
• Active bleeding causing anemia demands definitive surgical control—never delay when anemia is present 1
• Multiple hemorrhoid columns with extensive disease less amenable to office procedures 1

Critical pitfall: Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1.

Special Population: Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in third trimester 1, 4
• Conservative management with fiber (30g daily), adequate fluids, and bulk-forming agents (psyllium husk) is first-line 4
• Osmotic laxatives (polyethylene glycol, lactulose) are safe during pregnancy 4
• Hydrocortisone foam is safe in third trimester with no adverse events in prospective study of 204 patients 4
• For incarcerated, thrombosed hemorrhoids in pregnancy, approximately 0.2% require urgent hemorrhoidectomy 4

Critical pitfall: Avoid stimulant laxatives during pregnancy due to conflicting safety data 4.

Treatment Algorithm by Grade

Grade I (bleeding, no prolapse):

• Conservative management → Rubber band ligation if persistent → Sclerotherapy as alternative 1, 3

Grade II (prolapse with spontaneous reduction):

• Conservative management → Rubber band ligation (first-line procedure) → Hemorrhoidectomy if failed 1, 3

Grade III (requires manual reduction):

• Conservative management → Rubber band ligation → Hemorrhoidectomy for persistent symptoms or multiple columns 1, 3

Grade IV (irreducible):

• Hemorrhoidectomy is definitive treatment 1, 3

Monitoring and Follow-Up

• Reassess within 1-2 weeks if symptoms worsen or fail to improve 1
• Significant bleeding, severe pain, or fever requires emergency evaluation for potential necrotizing pelvic sepsis 1
• Perform colonoscopy if bleeding is atypical, no source evident on anorectal examination, or patient has risk factors for colonic neoplasia 1