What are the management options for hemorrhoids (piles)?

Management of Hemorrhoids (Piles)

First-Line Treatment: Conservative Management for All Grades

All patients with hemorrhoids should begin with conservative management consisting of increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining during defecation. 1, 2

• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) effectively soften stool and reduce straining 1
• This approach prevents progression and reduces bleeding episodes across all hemorrhoid grades 2
• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3

Topical Pharmacological Management

For symptomatic relief, topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution compared to 45.8% with lidocaine alone. 1, 2

• This combination works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Short-term topical corticosteroids (≤7 days maximum) can reduce inflammation but must be strictly time-limited to avoid perianal tissue thinning 1, 2
• Topical nitrates show good results but are limited by high incidence of headache 1

Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber band ligation is the first procedural intervention when conservative management fails, with success rates of 70-89% and superior efficacy compared to other office procedures. 1, 3

• 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 per session, though many practitioners limit to 1-2 columns 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Repeated banding needed in up to 20% of patients 3

Alternative Office Procedures

• Sclerotherapy: Suitable for grade I-II hemorrhoids with 70-85% short-term success, but long-term remission only in one-third of patients 1, 3
• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids but requires more repeat treatments 1, 3
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

Surgical Management: Hemorrhoidectomy

Conventional excisional hemorrhoidectomy is indicated for grade III-IV hemorrhoids, failure of conservative/office-based therapy, mixed internal-external hemorrhoids, or hemorrhoids causing anemia, with recurrence rates of only 2-10%. 1, 2, 3

Indications for Surgery

• Symptomatic grade III-IV hemorrhoids 1
• Failure of medical and office-based therapy 1
• Mixed internal and external hemorrhoids 1
• Anemia from hemorrhoidal bleeding 1
• Concomitant anorectal conditions requiring surgery 1

Surgical Techniques

• Ferguson (closed) technique: Primary wound closure, associated with reduced postoperative pain 1
• Milligan-Morgan (open) technique: No significant outcome difference from closed technique 1
• Postoperative pain requires narcotic analgesics with 2-4 weeks before return to work 1

Management of Thrombosed External Hemorrhoids

For presentation within 72 hours: Complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates. 1, 2, 3

For presentation beyond 72 hours: Conservative management with stool softeners, oral analgesics, and topical treatments is preferred as natural resolution has begun. 1, 3

Critical Pitfall

• Never perform simple incision and drainage of the thrombus—this leads to persistent bleeding and higher recurrence rates 1, 2

Special Population: Pregnancy

Hemorrhoids occur in approximately 80% of pregnant persons, with conservative management as the cornerstone throughout pregnancy. 4

• Psyllium husk and osmotic laxatives (polyethylene glycol, lactulose) are safe during pregnancy 4
• Hydrocortisone foam is safe in third trimester with no adverse events in prospective studies 4
• Avoid stimulant laxatives due to conflicting safety data 4
• For incarcerated/thrombosed hemorrhoids in pregnancy: approximately 0.2% require urgent hemorrhoidectomy 4

Procedures to Avoid

Anal dilatation should never be performed—52% incontinence rate at 17-year follow-up with sphincter injuries. 1

Cryotherapy should be avoided—prolonged pain, foul-smelling discharge, and greater need for additional therapy. 1

Critical Diagnostic Considerations

• Hemorrhoids alone do not cause positive fecal occult blood tests—colon must be adequately evaluated before attributing bleeding to hemorrhoids 1, 2
• Anemia from hemorrhoids is rare (0.5 per 100,000 population) and warrants colonoscopy to rule out proximal pathology 1
• Anal pain suggests other pathology (fissure, abscess, thrombosis) as uncomplicated hemorrhoids are typically painless 1
• Up to 20% of hemorrhoid patients have coexisting anal fissures 1, 4
• Colonoscopy indicated for atypical bleeding, significant risk factors for neoplasia, or when no source evident on anorectal examination 1, 2