What is the plan of care for a patient with hemorrhoids?

Hemorrhoid Plan of Care

All hemorrhoid patients should begin with conservative management including increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining during defecation, regardless of hemorrhoid grade or type. 1

Initial Assessment

• Perform digital rectal examination and anoscopy when tolerable to classify hemorrhoid type and grade 1
• Internal hemorrhoids are graded I-IV based on degree of prolapse: Grade I (bleeding only), Grade II (prolapse with spontaneous reduction), Grade III (requiring manual reduction), Grade IV (irreducible) 1
• External hemorrhoids typically cause symptoms only when thrombosed, presenting with acute pain and palpable perianal lump 1
• Rule out colorectal cancer with colonoscopy in patients ≥50 years or those with atypical bleeding, as hemorrhoids alone do not cause positive fecal occult blood tests 1
• Check hemoglobin if significant bleeding is present, as anemia from hemorrhoids is rare (0.5/100,000) and warrants definitive treatment 1

Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications

• Increase fiber intake to 25-30g daily using psyllium husk (5-6 teaspoonfuls with 600mL water daily) 1
• Increase water intake to soften stool and reduce straining 1
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1

Pharmacological Options

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 2
• Topical analgesics (lidocaine 1.5-2%) provide symptomatic relief of pain and itching 1
• Short-term topical corticosteroids (≤7 days maximum) may reduce perianal inflammation, but never exceed 7 days due to risk of mucosal thinning 1

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

Within 72 hours of symptom onset:

• Complete surgical excision under local anesthesia is the treatment of choice, providing faster pain relief and lower recurrence rates 1, 3
• Simple incision and drainage is contraindicated due to persistent bleeding and higher recurrence 1, 3

Beyond 72 hours of symptom onset:

• Conservative management is preferred as natural resolution has begun 1, 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for 2 weeks achieves 92% resolution rate (versus 45.8% with lidocaine alone) 1, 3
• No systemic side effects observed with topical nifedipine 1
• Stool softeners, oral analgesics (acetaminophen or ibuprofen), and topical treatments 1

If thrombosed hemorrhoid has burst:

• Clean area gently with warm water and mild soap 4
• Apply direct pressure if actively bleeding 4
• Surgical excision is generally unnecessary as natural drainage has occurred 4

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

Rubber Band Ligation (First-Line Procedural Treatment)

• Most effective office-based procedure with 70.5-89% success rate, superior to sclerotherapy and infrared coagulation 1, 2
• Band must be placed ≥2cm proximal to dentate line to avoid severe pain 1
• Can treat up to 3 hemorrhoids per session, though many limit to 1-2 columns 1
• Pain is most common complication (5-60%), typically manageable with sitz baths and over-the-counter analgesics 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic sepsis 1

Alternative Office Procedures

• Injection sclerotherapy: 70-85% short-term success for Grade I-II hemorrhoids, but only one-third achieve long-term remission 1, 2
• 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

Indications for Hemorrhoidectomy

• Failure of conservative and office-based therapies 1
• Symptomatic Grade III-IV hemorrhoids 1
• Mixed internal and external hemorrhoids 1
• Anemia from hemorrhoidal bleeding 1
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 1

Surgical Options

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard with lowest recurrence rate (2-10%) 1, 2
• Ferguson closed technique associated with reduced postoperative pain compared to open technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks 1
• Stapled hemorrhoidopexy shows less postoperative pain and faster recovery, but higher recurrence rate and lacks long-term follow-up data 1

Procedures to Avoid

• Anal dilatation should never be performed 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

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in third trimester 1
• Safe treatments include dietary fiber, adequate fluids, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in third trimester with no adverse events 1

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1
• Never use corticosteroid creams >7 days due to mucosal thinning risk 1
• Never perform simple incision and drainage of thrombosed hemorrhoids 1, 3
• Anal pain suggests other pathology (fissure, abscess, thrombosis) as uncomplicated internal hemorrhoids are painless 1
• Reassess if symptoms worsen or fail to improve within 1-2 weeks, or if significant bleeding, severe pain, or fever develop 1, 4