What are the treatment options for hemorrhoids?

Treatment for Hemorrhoids

All hemorrhoid treatment begins with conservative management—increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining—regardless of grade, with escalation to office procedures or surgery only when conservative measures fail. 1

Conservative Management (First-Line for All Grades)

Conservative therapy is the foundation of hemorrhoid treatment and should be attempted before any procedural intervention 1:

• Dietary fiber supplementation: 25-30 grams daily, achievable with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL water 1
• Adequate hydration: Increases stool bulk and softness, reducing straining 1
• Avoid prolonged straining: Critical to prevent worsening of symptoms 1
• Sitz baths: Warm water soaks reduce inflammation and provide symptomatic relief 1

Topical Pharmacological Options

For symptomatic relief, topical agents provide short-term benefit but lack evidence for reducing hemorrhoidal swelling, bleeding, or prolapse 1:

• Lidocaine 1.5-2% ointment: Apply as needed for pain and itching relief 1
• Topical nifedipine 0.3% with lidocaine 1.5%: Apply every 12 hours for 2 weeks—achieves 92% resolution rate for thrombosed external hemorrhoids versus 45.8% with lidocaine alone, with no systemic side effects 1
• 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 limited by high incidence of headache (up to 50%) 1

Systemic Pharmacological Options

• Flavonoids (phlebotonics): Relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3
• Oral analgesics: Acetaminophen or ibuprofen for additional pain control 1

Office-Based Procedures (Grade I-III Internal Hemorrhoids)

When conservative management fails after 1-2 weeks, rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids 1:

Rubber Band Ligation (Preferred)

• Success rates: 70.5-89% depending on hemorrhoid grade and follow-up duration 1
• Technique: Band placed at least 2 cm proximal to dentate line to avoid severe pain; up to 3 hemorrhoids can be banded per session, though many limit to 1-2 columns 1
• Advantages: More effective than sclerotherapy, requires fewer repeat treatments than infrared photocoagulation, performed in office without anesthesia 1
• Complications: Pain (5-60%, typically minor), bleeding when eschar sloughs (1-2 weeks post-treatment), abscess, urinary retention (5%) 1
• Contraindications: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic sepsis 1

Alternative Office Procedures (Less Effective)

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

Surgical Management

Hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal/external hemorrhoids, anemia from hemorrhoidal bleeding, and concomitant anorectal conditions requiring surgery 1:

Conventional Excisional Hemorrhoidectomy (Gold Standard)

• Indications: Grade III-IV hemorrhoids, failed conservative/office therapy, mixed disease, hemorrhoid-induced anemia 1, 4
• Techniques: Ferguson (closed) or Milligan-Morgan (open)—no significant outcome difference, though Ferguson associated with reduced postoperative pain and faster wound healing 1, 5
• Recurrence rate: 2-10% (lowest of all treatments) 1
• Recovery: Most patients require narcotic analgesics and 2-4 weeks off work 1
• Success rate: 90-98% for definitive control 1

Alternative Surgical Options

• Stapled hemorrhoidopexy: Faster recovery, shorter hospital stay, less postoperative pain, but higher recurrence rate than conventional hemorrhoidectomy 6, 5
• Hemorrhoidal artery ligation (HAL/RAR): Better tolerance but higher recurrence rate 5

Procedures to AVOID

• Anal dilatation: Abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1
• Cryotherapy: Rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Management of Thrombosed External Hemorrhoids

Timing of presentation determines treatment approach:

Early Presentation (Within 72 Hours)

Complete excision under local anesthesia is recommended—provides faster pain relief and reduces recurrence risk compared to conservative management 1, 3:

• Performed as outpatient procedure with low complication rates 1
• Never perform simple incision and drainage—leads to persistent bleeding and higher recurrence 1

Late Presentation (>72 Hours)

Conservative management is preferred once natural resolution has begun 1:

• Stool softeners to reduce straining 1
• Oral analgesics (acetaminophen, ibuprofen) 1
• Topical nifedipine 0.3% with lidocaine 1.5% every 12 hours for 2 weeks (92% resolution rate) 1
• Topical analgesics (lidocaine 5%) 1
• Short-term corticosteroids (≤7 days) 1

Treatment Algorithm by Grade

Grade I (Bleeding, No Prolapse)

1. Conservative management (fiber, fluids, lifestyle) 1
2. If persistent: Rubber band ligation or sclerotherapy 1

Grade II (Prolapse with Spontaneous Reduction)

1. Conservative management 1
2. If persistent: Rubber band ligation (preferred) 1
3. Alternative: Infrared photocoagulation or sclerotherapy 1

Grade III (Prolapse Requiring Manual Reduction)

1. Conservative management trial 1
2. Rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy 6
3. Surgical hemorrhoidectomy preferred for definitive treatment 1

Grade IV (Irreducible Prolapse)

Excisional hemorrhoidectomy or stapled hemorrhoidopexy—office procedures not appropriate 1, 6

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy—hemorrhoids alone do not cause positive stool guaiac tests; proximal colonic pathology must be ruled out 1, 4
• Never use corticosteroid creams >7 days—causes perianal tissue thinning and increased injury risk 1, 2
• Never perform simple incision and drainage of thrombosed hemorrhoids—leads to persistent bleeding and higher recurrence 1
• Never assume all anorectal symptoms are hemorrhoids—anal pain suggests alternative pathology (fissure, abscess, thrombosis) as uncomplicated hemorrhoids are typically painless 1, 4
• Anemia from hemorrhoids is rare (0.5/100,000 population)—when present, demands definitive surgical intervention 1, 4

When to Refer

Immediate referral indications 4:

• Anemia from hemorrhoidal bleeding 4
• Severe bleeding with hemodynamic instability 4
• Fever, severe pain, or signs of systemic infection (concern for necrotizing pelvic sepsis) 4
• Symptoms persisting >1-2 weeks despite appropriate conservative treatment 4
• Grade IV hemorrhoids (always require surgical evaluation) 4
• Failed rubber band ligation or recurrent symptoms after multiple office procedures 4