What is the first-line treatment for hemorrhoids?

First-Line Treatment for Hemorrhoids

The first-line treatment for all grades of hemorrhoids is conservative management with increased dietary fiber (25-30 grams daily) and water intake to soften stool and reduce straining, combined with topical treatments for symptomatic relief. 1, 2

Conservative Management (Initial Approach for All Patients)

All patients with hemorrhoids should begin with dietary and lifestyle modifications before any procedural intervention. 1, 3

Dietary Modifications

• Increase fiber intake to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) 1
• Increase water intake substantially to soften stool 1, 2
• Avoid straining during defecation 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) with no systemic side effects 1, 3
• Short-term topical corticosteroids (≤7 days maximum) can reduce local inflammation, but never exceed 7 days due to risk of perianal tissue thinning 1, 3
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for pain control 1
• Sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Adjuncts

• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Stool softeners to prevent straining 2

When to Escalate Beyond Conservative Management

If symptoms fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation and treatment escalation is necessary. 1

Office-Based Procedures (For Persistent Grade I-III Internal Hemorrhoids)

Rubber band ligation is the preferred first procedural intervention after conservative management fails, with success rates of 70.5-89% depending on hemorrhoid grade. 1, 3, 4

• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1, 4
• Can be performed in office without anesthesia 1
• Pain occurs in 5-60% of patients but is typically minor and manageable with sitz baths and over-the-counter analgesics 3, 5
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1

Alternative Office Procedures (If Rubber Band Ligation Fails or Is Contraindicated)

• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids 1, 3
• Sclerotherapy: suitable for grade I-II hemorrhoids, 70-85% short-term efficacy 1, 2

Surgical Management (Reserved for Specific Indications)

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, or mixed internal and external hemorrhoids. 1, 3

• Conventional excisional hemorrhoidectomy has the lowest recurrence rate (2-10%) but causes more postoperative pain requiring narcotic analgesics 1, 3, 2
• Most patients cannot return to work for 2-4 weeks after surgery 1

Special Considerations for Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours, excision under local anesthesia provides faster pain relief and reduced recurrence risk. 1, 2

For presentation beyond 72 hours, conservative management is preferred with stool softeners, oral and topical analgesics (5% lidocaine). 1, 2

• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without adequate colonic evaluation by colonoscopy 1
• Never use corticosteroid creams for more than 7 days—prolonged use causes perianal tissue thinning 1, 3
• Avoid anal dilatation entirely—52% incontinence rate at 17-year follow-up 1
• Avoid cryotherapy—causes prolonged pain, foul discharge, and requires more additional therapy 1
• Anal pain is generally NOT associated with uncomplicated hemorrhoids—its presence suggests anal fissure, abscess, or thrombosis 1