What percentage of lidocaine (local anesthetic) gel is used for pain relief from external hemorrhoids?

Lidocaine Gel for External Hemorrhoid Pain Relief

For external hemorrhoid pain relief, use 5% lidocaine ointment or cream applied topically to the affected area, or alternatively 2% lidocaine gel, with application frequency of 3 times daily as needed for symptomatic relief. 1, 2

Recommended Lidocaine Concentrations and Formulations

Prescription-Strength Options

• 5% lidocaine ointment is the most commonly recommended concentration for anorectal pain, applied topically to external hemorrhoids 3 times daily 2, 3
• This concentration has been proven systemically safe even with repeated anorectal administration, with plasma concentrations remaining well below therapeutic levels (peak concentrations around 145.9 ng/ml, far below the 1,500 ng/ml minimal effective therapeutic concentration) 3

Over-the-Counter Options

• 4% lidocaine cream is available over-the-counter in the United States and can provide effective topical analgesia 4
• This concentration is suitable for self-management of external hemorrhoid pain without requiring a prescription 4

Lower Concentration Alternatives

• 2% lidocaine gel or ointment can be used as an alternative, particularly when combined with other agents 5, 6
• When used alone, 2% lidocaine provides modest pain relief but is less effective than higher concentrations or combination therapies 6

Enhanced Efficacy with Combination Therapy

The most effective topical treatment for external hemorrhoids is 0.3% nifedipine combined with 1.5% lidocaine ointment, applied every 12 hours for two weeks, which achieves 92% resolution compared to only 45.8% with lidocaine alone. 1, 7

Mechanism and Benefits

• Nifedipine relaxes internal anal sphincter hypertonicity, which is a major contributor to hemorrhoid pain, while lidocaine provides immediate symptomatic relief 1
• This combination demonstrates complete pain relief in 86% of patients within 7 days, compared to only 50% with lidocaine alone 7
• No systemic side effects have been observed with topical nifedipine application 1, 7

Alternative Combination

• 2% lidocaine with 2% diltiazem applied 3 times daily reduces pain at 1 hour post-application and improves patient satisfaction, with approximately 45% less total analgesic requirement compared to placebo 6

Application Guidelines

Frequency and Duration

• Apply topical lidocaine 3 times daily for acute symptom management 3, 6
• For thrombosed external hemorrhoids, continue combination therapy (nifedipine/lidocaine) for 14 days to achieve optimal resolution 1, 7
• Single applications provide short-term relief (1-4 hours), making regular dosing necessary for sustained pain control 6

Safety Considerations

• Repeated anorectal administration of 5% lidocaine (2.5 g ointment containing 125 mg lidocaine three times daily) is safe, with minimal systemic absorption and accumulation 3
• Patients should be warned about potential self-limiting side effects of intravascular lidocaine absorption, such as tongue numbness or tinnitus, though these are rare 5

Clinical Context and Limitations

When Lidocaine Alone Is Insufficient

• Lidocaine provides only symptomatic relief and does not address the underlying pathophysiology of hemorrhoids 1
• For thrombosed external hemorrhoids presenting within 72 hours, surgical excision under local anesthesia provides faster pain relief and lower recurrence rates than topical therapy alone 1, 2
• For presentation beyond 72 hours, conservative management with topical analgesics (including 5% lidocaine) plus stool softeners is preferred, as the natural resolution process has begun 1, 2

Important Caveats

• Corticosteroid creams should never be used for more than 7 days when combined with lidocaine, as prolonged use causes thinning of perianal and anal mucosa 1
• Topical nitrates (nitroglycerin) show efficacy similar to nifedipine but are limited by high incidence of headache (up to 50% of patients) 1
• All patients with external hemorrhoids should receive concurrent conservative management including increased fiber (25-30 grams daily), adequate water intake, and avoidance of straining during defecation 1, 2