What are the management options for external hemorrhoids?

Management of External Hemorrhoids

External hemorrhoids should be managed conservatively with dietary modifications, topical treatments, and lifestyle changes as first-line therapy, with surgical excision reserved exclusively for thrombosed external hemorrhoids presenting within 72 hours of symptom onset. 1

Initial Conservative Management (First-Line for All External Hemorrhoids)

All external hemorrhoids begin with conservative therapy regardless of severity 1:

• Increase dietary fiber to 25-30 grams daily with adequate water intake (600 mL with each fiber dose) to soften stool and reduce straining 1, 2
• Avoid straining during defecation, as this is the primary exacerbating factor 1
• Regular sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1
• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements 1

Topical Pharmacological Management

For symptomatic external hemorrhoids, topical therapy provides substantial relief:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is the most effective topical treatment, achieving 92% resolution compared to 45.8% with lidocaine alone 1
• Nifedipine works by relaxing internal anal sphincter hypertonicity that perpetuates the pain cycle, while lidocaine provides immediate symptomatic relief 1
• No systemic side effects occur with topical nifedipine, making it safer than topical nitrates 1
• Topical corticosteroids may reduce local inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2
• 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

Management of Thrombosed External Hemorrhoids

The timing of presentation determines the treatment approach:

Presentation Within 72 Hours of Symptom Onset

Complete excision under local anesthesia in the office or clinic is the treatment of choice, providing faster pain relief and lower recurrence rates compared to conservative management 3, 1, 4:

• Excision can be safely performed as an outpatient procedure with low complication rates 1
• Never perform simple incision and drainage - this leads to persistent bleeding and significantly higher recurrence rates 1, 2
• Complete excision removes the entire thrombosed hemorrhoid, not just the clot 1

Presentation Beyond 72 Hours of Symptom Onset

Conservative management is preferred because the natural resolution process has already begun and pain typically resolves within 7-10 days 3, 1:

• Stool softeners to prevent straining 1, 4
• Oral analgesics (acetaminophen or ibuprofen) for pain control 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours 1
• Topical corticosteroids for ≤7 days only 1
• Regular sitz baths 1

When External Hemorrhoids Require Surgical Hemorrhoidectomy

Surgery is indicated only in specific circumstances 3:

• Mixed internal and external hemorrhoids with symptomatic external component that fails conservative and office-based therapy 3, 1
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids should undergo either hemorrhoidectomy or excision of the external component with rubber band ligation of internal hemorrhoids 3
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 3
• Patient preference after thorough discussion of treatment options 3

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days - prolonged use causes thinning of perianal and anal mucosa, increasing injury risk 1, 2
• Never perform simple incision and drainage of thrombosed external hemorrhoids - this leads to persistent bleeding and higher recurrence rates 1, 2
• Do not perform rubber band ligation on external hemorrhoids (except in the experimental context described in one 2025 study with local anesthesia injection) - external hemorrhoids are below the dentate line where somatic pain receptors are present, making this extremely painful 5
• Avoid topical nitrates as first-line therapy due to high incidence of headaches despite good pain relief 1
• Do not rely on suppositories as primary treatment - they provide only symptomatic relief with limited evidence for efficacy and no strong evidence for reducing hemorrhoidal swelling or bleeding 1

Important Diagnostic Considerations

• Severe anal pain suggests thrombosed external hemorrhoids, anal fissure (present in up to 20% of hemorrhoid patients), or perianal abscess - not uncomplicated external hemorrhoids 1, 6
• External hemorrhoids typically cause symptoms only when thrombosed 1
• Anoscopy should be performed when feasible to rule out other causes of anorectal symptoms 1
• Never attribute anemia to hemorrhoids without proper colonic evaluation - anemia from hemorrhoids is rare (0.5 patients/100,000 population) 1

Special Populations

Pregnant Patients

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, and osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in the third trimester 1

Immunocompromised Patients

• Patients with uncontrolled AIDS, neutropenia, or severe diabetes mellitus have increased risk of necrotizing pelvic infection 1
• Medical stabilization is required before any surgical intervention 2