What is the recommended treatment for acute hemorrhoids?

Acute Hemorrhoid Treatment

For acute hemorrhoids, begin immediately with conservative management (increased fiber/water intake, avoid straining) combined with topical 0.3% nifedipine plus 1.5% lidocaine ointment every 12 hours for 2 weeks, which achieves 92% resolution; if thrombosed external hemorrhoids present within 72 hours, surgical excision under local anesthesia provides faster relief and lower recurrence than conservative management alone. 1, 2

Initial Assessment and Classification

When evaluating acute hemorrhoids, determine:

• Timing of symptom onset (critical for thrombosed external hemorrhoids—the 72-hour window determines treatment approach) 1, 2
• Location: Internal (above dentate line) vs. external (below dentate line) vs. mixed 1, 3
• Presence of thrombosis: Acute-onset severe pain with palpable perianal lump indicates thrombosed external hemorrhoid 1, 2
• Severity of bleeding: Check vital signs and hemoglobin if significant bleeding present 4

Critical pitfall: Never attribute bleeding to hemorrhoids without proper evaluation—hemorrhoids alone do not cause positive fecal occult blood tests, and colonoscopy should be performed if bleeding is atypical or patient has risk factors for colonic neoplasia 1

Treatment Algorithm Based on Hemorrhoid Type

Thrombosed External Hemorrhoids

Within 72 hours of symptom onset:

• Surgical excision under local anesthesia is preferred, providing faster symptom resolution and significantly lower recurrence rates compared to conservative management 1, 2, 3
• This can be performed as an outpatient procedure with low complication rates 1
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1, 4, 2

Beyond 72 hours of symptom onset:

• Conservative management is preferred as natural resolution has begun 1, 2
• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks (92% resolution rate vs. 45.8% with lidocaine alone) 1, 2
• This works by relaxing internal anal sphincter hypertonicity without systemic side effects 1
• Add stool softeners and oral analgesics (acetaminophen or ibuprofen) 1, 3

Non-Thrombosed Internal or External Hemorrhoids

First-line conservative management (for all grades):

• Increase dietary fiber to 25-30 grams daily and water intake to soften stool and reduce straining 1, 4, 2
• Avoid straining during defecation 1, 2
• Warm sitz baths to reduce inflammation and discomfort 1

Pharmacological adjuncts:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks (highly effective for symptom relief) 1, 2
• Flavonoids (phlebotonics) such as micronized purified flavonoid fraction (MPFF/Daflon 500 mg) reduce bleeding, pain, and swelling 1, 2, 5, 6, 7
  • Dosing: 3 tablets twice daily for first 4 days, then 2 tablets twice daily for 3 days during acute episodes 7
  • Important limitation: Symptom recurrence reaches 80% within 3-6 months after cessation 1, 3
• Short-term topical corticosteroids (≤7 days only) for perianal inflammation 1, 2
  • Critical warning: Never use for more than 7 days—prolonged use causes thinning of perianal and anal mucosa 1, 2

Alternative topical agents (if nifedipine unavailable):

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

When Conservative Management Fails

For persistent grade I-III internal hemorrhoids:

• Rubber band ligation is the preferred office-based procedure, with success rates of 70.5-89% 1, 4, 3, 8
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Must place band at least 2 cm proximal to dentate line to avoid severe pain 1
• Can treat 1-3 hemorrhoid columns per session 1

For grade III-IV hemorrhoids or failed office procedures:

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) achieves lowest recurrence rate (2-10%) 1, 3, 8
• Major drawback is postoperative pain requiring narcotics, with 2-4 weeks before return to work 1
• Reserved for recurrent disease, mixed internal/external hemorrhoids, or when concomitant conditions (fissure, fistula) require surgery 1

Special Situations

Hemorrhoids with anemia:

• Hemorrhoidectomy is indicated when hemorrhoidal bleeding has caused anemia—this represents a critical threshold requiring definitive surgical intervention 1
• Never delay definitive treatment when active bleeding has caused anemia 1
• Obtain colonoscopy to rule out proximal colonic pathology 1

Pregnant patients:

• Safe treatments include dietary fiber, adequate fluids, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol, lactulose) 1
• Hydrocortisone foam can be used safely in third trimester 1

Reassessment Triggers

Seek further evaluation if:

• Symptoms worsen or fail to improve within 1-2 weeks 1, 2
• Significant bleeding, severe pain, or fever develop 1
• Inability to tolerate examination (may indicate necrotizing pelvic sepsis, especially in immunocompromised patients) 1

Procedures to Avoid

• Anal dilatation: Abandoned due to 52% incontinence rate at 17-year follow-up 1
• Cryotherapy: Rarely used due to prolonged pain, foul-smelling discharge, and need for additional therapy 1
• Simple incision and drainage of thrombosed hemorrhoids: Leads to persistent bleeding and higher recurrence 1, 4, 2