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 with adequate water intake to soften stool and reduce straining 1
- Avoid straining during defecation to prevent symptom exacerbation 1
- Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1
Topical Pharmacological Treatment
Most Effective Option
- Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks shows 92% resolution rate 1
- Works by relaxing internal anal sphincter hypertonicity that contributes to pain 1
- No systemic side effects have been observed with topical nifedipine 1
Alternative Topical Agents
- Topical corticosteroids 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 oral analgesics (acetaminophen or ibuprofen) for additional pain control 1
Management of Thrombosed External Hemorrhoids
Timing-Based Algorithm
If presenting within 72 hours of symptom onset:
- Complete excision under local anesthesia as an outpatient procedure is recommended 1
- Provides faster pain relief and reduces risk of recurrence compared to conservative management 1
- Never perform simple incision and drainage - this leads to persistent bleeding and higher recurrence rates 1
If presenting >72 hours after onset:
- Conservative management is preferred as natural resolution has begun 1
- Stool softeners, oral and topical analgesics (5% lidocaine) 1, 2
- Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks 1
- Topical muscle relaxants for additional pain relief with severe sphincter spasm 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
- ~90% patient satisfaction rate 3
- This represents a departure from traditional teaching that rubber band ligation should only be used for internal hemorrhoids 3
Surgical Hemorrhoidectomy
Indications for surgery: 1
- Failure of conservative and topical treatments
- Mixed internal and external hemorrhoids
- Recurrent thrombosis despite conservative management
Surgical approach: 4
- Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) with recurrence rate of 2-10% 4
- Narcotic analgesics generally required postoperatively 4
- Most patients not returning to work for 2-4 weeks 4
Critical Pitfalls to Avoid
- Never use corticosteroid creams for >7 days - causes perianal tissue thinning and increased injury risk 1
- Never perform simple incision and drainage of thrombosed external hemorrhoids - leads to persistent bleeding and higher recurrence 1
- Never attribute anemia or positive fecal occult blood to hemorrhoids without proper colonic evaluation 1
- Watch for necrotizing pelvic sepsis - clinical triad of severe pain, high fever, and urinary retention requires emergency intervention 5
- Increased risk in immunocompromised patients (uncontrolled diabetes, immunosuppressive medications) 5
Special Populations
Pregnant patients: 1