From the Guidelines
Hemorrhoids can be effectively treated with non-operative management as first-line therapy, focusing on dietary and lifestyle changes, and the administration of flavonoids to relieve symptoms. This approach is based on the most recent and highest quality evidence available, specifically the 2021 guidelines from the World Journal of Emergency Surgery 1. The recommended dietary and lifestyle changes include increasing fiber and water intake, as well as adopting adequate bathroom habits.
Key aspects of treatment include:
- Increasing fiber intake to reduce symptoms and prevent recurrence
- Drinking plenty of water to soften stool and reduce straining
- Administering flavonoids to relieve symptoms, as suggested by the guidelines 1
- Considering topical muscle relaxants for thrombosed or strangulated hemorrhoids, although the evidence for this is weaker 1
It's essential to note that the use of NSAIDs, topical steroids, and other topical agents is not recommended due to the lack of evidence supporting their effectiveness in treating complicated hemorrhoids 1. For persistent or severe cases, medical treatments like rubber band ligation or surgical removal may be necessary, but these should be considered after non-operative management has been attempted. The goal of treatment is to reduce morbidity, mortality, and improve quality of life by alleviating symptoms and preventing recurrence.
In terms of specific treatments, the guidelines suggest that flavonoids can be beneficial in relieving symptoms 1, and other studies have shown that oral micronized, purified flavonoid fraction (MPFF) can increase venous tone, lymphatic drainage, and capillary resistance, and normalize capillary permeability 1. However, the most recent and highest quality evidence should always be prioritized, and in this case, the 2021 guidelines from the World Journal of Emergency Surgery provide the strongest recommendation for non-operative management as first-line therapy 1.
From the Research
Treatment Options for Hemorrhoids
- Conservative treatment is effective in managing the majority of patients complaining of early stages of the disease, including dietary and lifestyle modifications, oral phlebotonic drugs, and topical medications 2
- Rubber band ligation and phlebotonic drugs can effectively treat grade I and II hemorrhoids 3
- Surgery is required for the most advanced stages of hemorrhoids, with Milligan-Morgan hemorrhoidectomy considered the gold-standard approach for grade IV hemorrhoids 3
- Minimally invasive treatment options, including mucopexy with or without mucosal resection and hemorrhoid artery ligation, are available for the management of grade III hemorrhoids 3
- Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is the mainstay of initial therapy for hemorrhoids 4
- Office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step if medical management is unsuccessful 4
- Excision of thrombosed external hemorrhoids can greatly reduce pain if performed within the first two to three days of symptoms 4
- Low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures, such as rubber band ligation and injection sclerotherapy 5
- Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred 5
- Minimally invasive operations, including Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation, and stapled hemorrhoidopexy, have been introduced to avoid post-hemorrhoidectomy pain 5
Factors to Consider in Treatment
- Hemorrhoidal size, thrombosis, and location determine the extent of pain or discomfort 4
- Internal hemorrhoids are traditionally graded from I to IV based on the extent of prolapse 4
- Degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued 4
- Treatment can be individualized based on the unique needs of each patient 6