What are the treatment options for hemorrhoids?

Hemorrhoid Treatment

First-Line Conservative Management for All Hemorrhoid Grades

All patients with hemorrhoids should begin with conservative management including increased dietary fiber (25-30 grams daily), adequate water intake (600 mL with fiber supplements), and avoidance of straining during defecation. 1, 2

• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) help regulate bowel movements and soften stool 1
• Sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1
• This conservative approach is recommended as first-line therapy regardless of hemorrhoid grade before proceeding to procedural interventions 1

Pharmacological Treatment Options

Topical Medications

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

• Nifedipine works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Lidocaine provides symptomatic relief of local pain and itching 1, 2
• Topical corticosteroid creams may reduce perianal 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, 2

Systemic Medications

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2, 3
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) provide additional pain control 1

Critical Pitfall: Suppository medications provide only symptomatic relief with no strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion—avoid relying on these as primary treatment 1

Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails. 1, 3

Rubber Band Ligation

• Success rates range from 70.5% to 89% depending on hemorrhoid grade 1, 4
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• Can be performed in office without anesthesia; up to 3 hemorrhoids can be banded in a single session 1
• Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Pain is the most common complication (5-60% of patients) but typically manageable with sitz baths and over-the-counter analgesics 1

Contraindication: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic infection and should not undergo rubber band ligation 1

Alternative Office Procedures

• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids but requires more repeat treatments 1
• Sclerotherapy: Suitable for grade I-II hemorrhoids, causing fibrosis and tissue shrinkage, but less effective than rubber band ligation 1, 3
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for: 1, 5

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

Surgical Techniques

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard for grade IV hemorrhoids with recurrence rates of only 2-10%. 1, 4, 3

• Ferguson (closed) technique involves primary wound closure and is associated with reduced postoperative pain and faster wound healing compared to Milligan-Morgan (open) technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1, 4
• Stapled hemorrhoidopexy offers faster recovery but higher recurrence rates 4, 3

Procedures to Avoid:

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

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours: Complete excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management 1, 3

For presentation >72 hours: Conservative management is preferred as natural resolution has begun 1, 3

• Stool softeners
• Oral and topical analgesics (5% lidocaine)
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1

Critical Pitfall: Never perform simple incision and drainage of the thrombus alone—this leads to persistent bleeding and higher recurrence rates 1

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 (concern for necrotizing pelvic sepsis)
• Grade IV hemorrhoids (always require surgical evaluation)

Referral After Treatment Failure 5

• Symptoms persisting or worsening despite 1-2 weeks of appropriate conservative treatment
• Grade II-III hemorrhoids with persistent bleeding or prolapse despite office procedures
• Rubber band ligation failure or recurrent symptoms after multiple procedures

Critical Diagnostic Pitfall: Never attribute anemia or fecal occult blood positivity to hemorrhoids without colonoscopy to rule out proximal colonic pathology—anemia from hemorrhoids is rare (0.5 patients/100,000 population) 1, 5