What are the management options for hemorrhoids?

Management of Hemorrhoids

First-Line Conservative Management for All Grades

All hemorrhoid grades should initially receive conservative management with dietary modifications, increased fiber (25-30 grams daily) and water intake to soften stool and reduce straining, regardless of severity. 1

• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements and are safe even in pregnancy 1
• Warm sitz baths reduce inflammation and discomfort 1
• Avoid straining during defecation to prevent symptom exacerbation 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1

Topical Treatments for Symptom Relief

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is highly effective (92% resolution rate) compared to lidocaine alone (45.8%) 1
• This 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 maximum 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%) 1
• Topical heparin significantly improves healing, though evidence is limited to small studies 1

Critical Pitfall: Never use corticosteroid creams for more than 7 days—prolonged use causes tissue thinning and increases injury risk 1

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Office-Based Procedures for Grade I-III Internal Hemorrhoids

When conservative management fails after 1-2 weeks, proceed to office-based interventions 1

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure for persistent grade I-III internal hemorrhoids, with success rates of 70.5-89% depending on grade. 1

• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or 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 many practitioners prefer 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients) but is 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 infection 1, 2

Critical Pitfall: Necrotizing pelvic sepsis is rare but serious—watch for severe pain, high fever, and urinary retention requiring emergency evaluation 1

Alternative Office Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage 1
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

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Surgical Management for Grade III-IV Hemorrhoids

Indications for Surgery

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 (fissure, fistula) requiring surgery

Surgical Options

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with the lowest recurrence rate of 2-10%. 1

• Ferguson (closed) technique involves primary wound closure and is associated with reduced postoperative pain and faster wound healing compared to Milligan-Morgan (open) 2
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Success rate approaches 90-98% with low recurrence 1

Stapled hemorrhoidopexy has advantages of reduced postoperative pain, shorter operation time and hospital stay, and faster recovery, but has a higher recurrence rate compared to conventional hemorrhoidectomy 2

Procedures to Avoid:

• Anal dilatation should never be performed—52% incontinence rate at 17-year follow-up and causes sphincter injuries 1
• Cryotherapy should be avoided—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 of symptom onset:

• Complete excision under local anesthesia is recommended as an outpatient procedure, providing faster pain relief and lower recurrence rates 1, 3
• Never perform simple incision and drainage—this leads to persistent bleeding and significantly higher recurrence rates 1, 3

For presentation >72 hours or improving symptoms:

• Conservative management is preferred with stool softeners, oral and topical analgesics 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1
• Topical muscle relaxants for additional pain relief with severe sphincter spasm 1

Management of Burst Thrombosed Hemorrhoid

When a thrombosed hemorrhoid has already ruptured, surgical excision is generally not necessary as natural drainage has occurred. 3

• Clean the area gently with warm water and mild soap 3
• Apply direct pressure if active bleeding is present 3
• Continue conservative management with topical nifedipine/lidocaine and short-term corticosteroids (≤7 days) 3
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 3

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Special Populations and Situations

Hemorrhoids with Anemia

When hemorrhoids cause anemia with active bleeding on anoscopy, hemorrhoidectomy is indicated as this represents a critical threshold demanding definitive surgical intervention. 1

• Multiple hemorrhoid columns with active bleeding and anemia exceed the threshold for conservative management 1
• Blood transfusion may be needed given low hemoglobin levels 1
• Always perform colonoscopy to rule out proximal colonic pathology—never attribute anemia to hemorrhoids without proper evaluation 1

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely 1
• Hydrocortisone foam can be used safely in the third trimester with no adverse events 1

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Critical Diagnostic Considerations

Never assume all anorectal symptoms are due to hemorrhoids—other conditions frequently coexist or are the primary cause. 1

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Anal pain is generally NOT associated with uncomplicated hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids), abscess, or thrombosis 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) 1
• Anoscopy should be performed when feasible to rule out other causes of anorectal symptoms 1
• Colonoscopy should be considered if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 1, 2

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When to Escalate Care

Reassessment is necessary if: 1, 3

• Symptoms worsen or fail to improve within 1-2 weeks of treatment
• Significant bleeding occurs
• Severe pain develops
• Fever is present
• Signs of hemodynamic instability appear