What are the management options for hemorrhoids?

Management of Hemorrhoids

First-Line Conservative Management for All Grades

All hemorrhoids, regardless of grade or type, should initially be managed with dietary and lifestyle modifications, including increased fiber (25-30 grams daily) and water intake to produce soft, bulky stools, combined with avoidance of straining during defecation. 1, 2

• Fiber supplementation (such as psyllium husk at 5-6 teaspoonfuls with 600 mL water daily) helps regulate bowel movements and reduces hemorrhoidal symptoms 1
• This conservative approach should be attempted for 1-2 weeks before escalating to procedural interventions 1, 2
• Warm sitz baths can reduce inflammation and provide symptomatic relief 1

Pharmacological Management

For Symptomatic Relief (All Types)

• 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, 2
• This combination works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3

Topical Corticosteroids: Critical Limitation

• Corticosteroid creams should NEVER be used for more than 7 days due to risk of perianal and anal mucosa thinning 1, 2
• While they reduce local inflammation, prolonged use increases injury risk 1

Alternative Topical Agents

• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1
• Topical heparin significantly improves healing, though evidence is limited to small studies 1

Office-Based Procedures for Internal Hemorrhoids

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 after conservative management fails, with success rates of 70.5-89%. 1, 3

• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can be performed in office without anesthesia 1
• 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 to 1-2 columns 1
• Repeated banding needed in up to 20% of patients 3

Contraindications for Rubber Band Ligation

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic infection 1
• Acutely thrombosed or irreducible hemorrhoids 1

Alternative Office Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 3
• Infrared photocoagulation has 67-96% success for grade I-II hemorrhoids but requires more repeat treatments 1, 3
• Bipolar diathermy achieves 88-100% bleeding control for grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for: 1, 3

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

Surgical Techniques

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard with lowest recurrence rate of 2-10% 1, 3
• No significant difference in outcomes between open and closed techniques 1
• Stapled hemorrhoidopexy has advantages of reduced postoperative pain and faster recovery but higher recurrence rates 4
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Procedures to AVOID

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

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours of symptom onset:

• Complete excision under local anesthesia is the treatment of choice, providing faster pain relief and lower recurrence rates 1, 2, 3
• NEVER perform simple incision and drainage alone—this leads to persistent bleeding and higher recurrence 1, 2

For presentation beyond 72 hours:

• Conservative management is preferred as natural resolution has begun 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 2
• Stool softeners and oral/topical analgesics (5% lidocaine) 3
• Reassess if symptoms worsen or fail to improve within 1-2 weeks 1, 2

Critical Diagnostic Pitfalls

When to Investigate Further

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Anemia from hemorrhoids is rare (0.5 per 100,000 population)—always perform colonoscopy to rule out proximal colonic pathology 1
• Anal pain is generally NOT associated with uncomplicated hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in up to 20% of hemorrhoid patients), abscess, or thrombosis 1
• Colonoscopy should be performed if bleeding is atypical, no source evident on anorectal examination, or patient has significant risk factors for colonic neoplasia 1, 2

Special Populations

Pregnancy

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

Hemorrhoids with Anemia

When hemorrhoids present with active bleeding and anemia, hemorrhoidectomy is indicated as it represents a critical threshold demanding definitive surgical intervention. 1

• Active bleeding on anoscopy with low hemoglobin indicates substantial chronic blood loss requiring definitive control 1
• Blood transfusion may be needed, and preoperative optimization should be considered if hemodynamically stable 1
• Never delay definitive treatment when active bleeding has caused anemia 1