What are the treatment options for hemorrhoids?

Hemorrhoid Treatment

Start all hemorrhoid patients with conservative management—increased dietary fiber (25-30 grams daily), adequate water intake, and avoidance of straining during defecation—then escalate to office-based procedures (rubber band ligation for grades I-III) or surgical hemorrhoidectomy (for grades III-IV or failed conservative therapy). 1

Initial Conservative Management (First-Line for All Grades)

All hemorrhoid patients should begin with dietary and lifestyle modifications regardless of grade 1:

• Increase dietary fiber to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1
• Adequate fluid intake to maintain soft, bulky stools 1
• Avoid straining during defecation, which exacerbates hemorrhoidal symptoms 1
• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2

Topical Treatments for Symptom Relief

For symptomatic relief during conservative management 1:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate (versus 45.8% with lidocaine alone) for thrombosed external hemorrhoids, with no systemic side effects 1
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1

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

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

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids 1:

• Success rates: 70.5%-89% depending on hemorrhoid grade and follow-up duration 1
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 3, 1
• 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 one session, though many practitioners limit treatment to 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients), 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

Alternative Office-Based Procedures

If rubber band ligation is contraindicated or fails 3, 1:

• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, but requires more repeat treatments 1
• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 1
• Sclerotherapy: Suitable for grade I-II hemorrhoids, 70-85% short-term efficacy but only one-third achieve long-term remission 1, 2

Surgical Management (For Grade III-IV or Failed Conservative/Office Therapy)

Indications for Hemorrhoidectomy

Surgical 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 (critical threshold demanding definitive surgical intervention) 1
• Concomitant anorectal conditions (fissure, fistula) requiring surgery
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids

Surgical Techniques

Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with recurrence rates of only 2-10% 1, 2:

• Ferguson (closed) technique: Primary wound closure, associated with reduced postoperative pain and faster wound healing compared to Milligan-Morgan (open) technique 1
• Milligan-Morgan (open) technique: Wounds left open to heal by secondary intention 3
• Major drawback: Postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Stapled hemorrhoidopexy 2:

• Faster postoperative recovery (9-14 days versus conventional hemorrhoidectomy)
• Higher recurrence rate compared to excisional hemorrhoidectomy
• Particularly advisable for circular hemorrhoids

Procedures to Avoid

Never perform these procedures 1:

• Anal dilatation: 52% incontinence rate at 17-year follow-up, causes sphincter injuries 1
• Cryotherapy: Prolonged pain, foul-smelling discharge, greater need for additional therapy 1

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

For thrombosed external hemorrhoids presenting within 72 hours, complete excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management 1, 2:

• Can be performed as outpatient procedure with low complication rates 1
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1

Late Presentation (>72 Hours)

For presentation beyond 72 hours, conservative management is preferred 1, 2:

• Stool softeners
• Oral analgesics (acetaminophen or ibuprofen)
• Topical 5% lidocaine for pain relief
• Topical 0.3% nifedipine with 1.5% lidocaine ointment (92% resolution rate) 1
• Symptoms typically improve as natural resolution process begins

Critical Diagnostic Pitfalls to Avoid

Never assume all anorectal symptoms are hemorrhoids 1:

• Anal pain is generally NOT associated with uncomplicated hemorrhoids—its presence suggests anal fissure (occurs in up to 20% of hemorrhoid patients), abscess, or thrombosis 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 by colonoscopy 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population)—never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1
• Fever should never be attributed to hemorrhoids alone—it indicates infection requiring immediate evaluation for abscess or necrotizing pelvic sepsis 4

When to Refer for Specialist Evaluation

Immediate referral indications 5:

• Anemia from hemorrhoidal bleeding
• Severe bleeding with hemodynamic instability
• Fever, severe pain, or signs of systemic infection (suggests necrotizing pelvic sepsis or perianal abscess)
• Symptoms lasting >1-2 weeks despite appropriate conservative treatment
• Grade IV hemorrhoids (always require surgical evaluation)
• Mixed internal and external hemorrhoids with failed conservative therapy
• Thrombosed external hemorrhoids within 72 hours if surgical excision is being considered

Antibiotic Use in Hemorrhoidal Disease

Antibiotics should NOT be routinely prescribed for hemorrhoids 4:

• Only indicated for perianal abscess formation (fluoroquinolones or third-generation cephalosporin plus metronidazole) or necrotizing pelvic sepsis (immediate broad-spectrum antibiotics and surgical consultation) 4
• Signs requiring antibiotics: fever >38.5°C, tachycardia, hypotension, elevated white blood cell count, fluctuance, or purulent drainage 4

Special Populations

Pregnancy

Safe treatments during pregnancy 1:

• Dietary fiber and adequate fluid intake
• Bulk-forming agents (psyllium husk)
• Osmotic laxatives (polyethylene glycol or lactulose)
• Hydrocortisone foam in third trimester (no adverse events versus placebo in prospective study of 204 patients)

Immunocompromised Patients

Lower threshold for referral and avoid rubber band ligation due to increased risk of necrotizing pelvic infection 1, 4