What treatment options are available for hemorrhoids, including over-the-counter medications like Preparation H (hydrocortisone) and prescription-strength alternatives?

Treatment Options for Hemorrhoids: Over-the-Counter and Prescription Alternatives

For symptomatic hemorrhoids, start with conservative management (increased fiber, water intake, and avoidance of straining) combined with short-term topical treatments, reserving prescription-strength interventions for refractory cases or specific clinical scenarios. 1

Over-the-Counter Preparation H (Hydrocortisone)

Standard Formulation and Usage

• Preparation H with hydrocortisone 1% cream is available over-the-counter for topical application to reduce perianal inflammation and itching. 2
• The FDA label specifies this is for external use only, and must be limited to no more than 7 days of continuous use to avoid thinning of perianal and anal mucosa. 1, 2
• Apply topically to the affected area as directed on the package, avoiding direct insertion into the rectum with fingers or mechanical devices. 2

Important Limitations and Warnings

• Stop use immediately if symptoms persist beyond 7 days, worsen, or if rectal bleeding occurs. 2
• Hydrocortisone suppositories and creams provide only symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion. 1
• Never use corticosteroid preparations long-term due to risk of tissue thinning and increased injury risk. 1

Superior Prescription-Strength Topical Alternatives

First-Line Prescription Option: Nifedipine/Lidocaine Combination

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves a 92% resolution rate compared to only 45.8% with lidocaine alone for thrombosed external hemorrhoids. 1, 3
• This combination works by relaxing internal anal sphincter hypertonicity (nifedipine) while providing immediate pain relief (lidocaine). 1
• No systemic side effects have been observed with topical nifedipine application, making it safer than systemic alternatives. 1
• This is particularly effective for external hemorrhoids and thrombosed hemorrhoids presenting beyond 72 hours when surgery is not indicated. 1

Alternative Prescription Topicals

• Topical nitrates (nitroglycerin ointment) show good results for thrombosed hemorrhoids but are limited by a high incidence of headache (up to 50% of patients). 1
• Contraindicated in patients with hypotension (SBP < 90 mmHg), extreme bradycardia (< 50 bpm), tachycardia (> 100 bpm), or those taking erectile dysfunction medications (sildenafil, tadalafil, vardenafil) due to severe hypotension risk. 1
• Topical heparin has shown promise in improving healing of acute hemorrhoids, though evidence is limited to small studies. 1

Conservative Management (Foundation for All Treatment)

Dietary and Lifestyle Modifications

• Increase dietary fiber intake to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily). 1, 3
• Adequate water intake helps soften stools and reduce straining during defecation. 1, 3
• Avoid prolonged straining and sitting on the toilet. 1

Adjunctive Measures

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

Office-Based Procedures for Persistent Internal Hemorrhoids

Rubber Band Ligation (First-Line Procedural Intervention)

• Rubber band ligation is the most effective office-based procedure for grade I-III internal hemorrhoids after conservative management fails, with success rates ranging from 70.5% to 89%. 1, 3
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation. 1
• Can be performed in an office setting without anesthesia, with up to 3 hemorrhoids banded in a single session. 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain. 1

Alternative Office Procedures

• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments. 1
• Injection sclerotherapy is suitable for first and second-degree hemorrhoids but less effective than rubber band ligation. 1

Surgical Management for Advanced Disease

Indications for Hemorrhoidectomy

• Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and anemia from hemorrhoidal bleeding. 1, 3
• Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) is the most effective treatment overall with a low recurrence rate of 2-10%. 1, 3

Thrombosed External Hemorrhoids

• For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, complete surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates. 1, 3, 4
• For presentations beyond 72 hours, conservative management with topical nifedipine/lidocaine is preferred, as the natural resolution process has begun. 1
• Never perform simple incision and drainage of the thrombus—this leads to persistent bleeding and higher recurrence rates. 1, 3

Special Population: Pregnancy

Safe Treatment Options

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester. 4
• Bulk-forming agents like psyllium husk and osmotic laxatives (polyethylene glycol or lactulose) are safe during pregnancy. 4
• Hydrocortisone foam has been shown safe in the third trimester with no adverse events compared to placebo in a prospective study of 204 patients. 1, 4
• Stimulant laxatives should be avoided due to conflicting safety data. 4

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to rule out proximal colonic pathology. 1, 3
• 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). 1
• Avoid anal dilatation 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