What is the recommended treatment for hemorrhoids?

Treatment of Hemorrhoids

First-Line Conservative Management for All Grades

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

• Dietary fiber supplementation with psyllium husk (5-6 teaspoonfuls with 600 mL water daily) prevents progression and reduces bleeding episodes 2
• This approach is effective across all hemorrhoid grades and should be maintained even when procedural interventions are planned 1, 3
• Phlebotonics (flavonoids) provide symptomatic relief for bleeding, pain, and swelling, though 80% of patients experience symptom recurrence 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, making it the most effective topical treatment. 1, 2, 4

• This combination works by relaxing internal anal sphincter hypertonicity without systemic side effects 1, 4
• Short-term topical corticosteroids (≤7 days maximum) may reduce perianal inflammation but must be strictly time-limited to prevent mucosal thinning 1, 2, 4
• Critical pitfall: Never use corticosteroid creams for more than 7 days as prolonged use causes tissue thinning and increased injury risk 1
• Topical nitrates show efficacy but are limited by headache in up to 50% of patients 1, 4

Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber band ligation is the first-line procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails, with success rates of 70-89%. 1, 2, 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 in a single session, though many practitioners limit treatment to 1-2 columns at a time 1
• Rubber band ligation is more effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Repeat banding is needed in up to 20% of patients 3

Alternative office procedures include:

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

Surgical Management

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

• The Ferguson (closed) technique is associated with reduced postoperative pain and faster wound healing compared to the Milligan-Morgan (open) technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks 1
• Hemorrhoidectomy is specifically indicated when hemorrhoidal bleeding has caused anemia, as this represents substantial chronic blood loss requiring definitive control 1

Procedures to avoid:

• Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up 1, 2
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and need for additional therapy 1, 2

Management of Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management. 1, 2, 4, 3

• Critical pitfall: Never perform simple incision and drainage alone—this leads to persistent bleeding and significantly higher recurrence rates 1, 4
• For presentation beyond 72 hours, conservative management is preferred as natural resolution has begun 1, 4
• Conservative management includes stool softeners, oral analgesics, topical 0.3% nifedipine with 1.5% lidocaine, and sitz baths 1, 4

Important Diagnostic Considerations

Hemorrhoids alone do not cause positive fecal occult blood tests or anemia—colonoscopy must be performed to exclude proximal colonic pathology before attributing these findings to hemorrhoids. 1, 2

• Anemia from hemorrhoidal disease is rare (0.5 per 100,000 population) 1
• Anal pain is generally not associated with uncomplicated hemorrhoids; its presence suggests anal fissure (occurs in 20% of hemorrhoid patients), abscess, or thrombosis 1
• Complete colonic evaluation is indicated when bleeding is atypical, no source is evident on examination, or the patient has risk factors for colorectal cancer 1, 5

Treatment Algorithm Summary

1. All patients: Conservative management (fiber, fluids, avoid straining) 1, 2
2. Symptomatic relief: Topical nifedipine 0.3% + lidocaine 1.5% every 12 hours for 2 weeks 1, 2, 4
3. Persistent grade I-III internal hemorrhoids: Rubber band ligation 1, 2, 3
4. Grade III-IV, mixed disease, or failed office procedures: Excisional hemorrhoidectomy 1, 2, 3
5. Thrombosed external hemorrhoids <72 hours: Surgical excision 1, 2, 4
6. Thrombosed external hemorrhoids >72 hours: Conservative management 1, 4