What are the treatment options for hemorrhoids?

Hemorrhoid Treatment

Start all hemorrhoid patients with conservative management—increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining—as first-line therapy regardless of hemorrhoid grade. 1

Conservative Management (First-Line for All Grades)

Dietary and lifestyle modifications form the foundation of hemorrhoid treatment and should be initiated immediately:

• Increase fiber intake to 25-30 grams daily, achievable with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL water daily 1
• Maintain adequate hydration to soften stool and reduce straining 1
• Take regular warm sitz baths to reduce inflammation and discomfort 1
• Avoid prolonged straining during defecation 1

Pharmacological adjuncts for symptom relief:

• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate (compared to 45.8% with lidocaine alone) for thrombosed external hemorrhoids, with no systemic side effects 1
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for additional pain control 1

Critical pitfall: Topical suppositories provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion—they should not be relied upon as primary treatment 1

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

If conservative management fails after 4-8 weeks, proceed to office-based interventions:

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure for grade I-III internal hemorrhoids, with success rates of 70.5-89%. 1, 2

• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can be performed in office without anesthesia 1
• Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners limit treatment to 1-2 columns at a time 1
• Repeated banding needed in up to 20% of patients 2

Complications: Pain (5-60% of patients, typically minor and manageable with sitz baths and over-the-counter analgesics), band slippage, prolapse/thrombosis of adjacent hemorrhoids (~5%), severe bleeding when eschar sloughs (1-2 weeks post-treatment), and rare necrotizing pelvic sepsis 1

Contraindication: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) have increased risk of necrotizing pelvic infection 1

Alternative Office Procedures

• Injection sclerotherapy: Suitable for grade I-II hemorrhoids, causing fibrosis and tissue shrinkage; 70-85% short-term efficacy but only one-third achieve long-term remission 1, 2
• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, but requires more repeat treatments 1, 2
• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management (For Grade III-IV or Failed Conservative/Office Therapy)

Surgical hemorrhoidectomy is indicated when:

• Medical and office-based therapy have failed after adequate trial 1, 3
• Symptomatic grade III-IV hemorrhoids are present 1
• Mixed internal and external hemorrhoids with extensive external component 1, 3
• Persistent bleeding causing anemia 1, 3
• Concomitant conditions (fissure, fistula) require surgery 1

Conventional Excisional Hemorrhoidectomy (Gold Standard)

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with recurrence rates of only 2-10%. 1, 4, 2

• Ferguson (closed) technique involves excising hemorrhoid components and closing wounds primarily, associated with reduced postoperative pain and faster healing compared to open technique 4, 3
• Milligan-Morgan (open) technique leaves wounds open to heal secondarily over 4-8 weeks 4
• Randomized trials show no consistent difference in postoperative pain between open and closed techniques 4

Major drawback: Postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks 1, 4

Complications: Urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), incontinence (2-12%), and sphincter defects documented in up to 12% of patients 1, 4

Stapled Hemorrhoidopexy

• Performs circular excision of internal hemorrhoids and prolapsing rectal mucosa proximal to the dentate line 4
• Significantly less postoperative pain and faster recovery than conventional hemorrhoidectomy 4, 5
• Higher recurrence rate compared to conventional hemorrhoidectomy 5, 2
• Rare but serious complications include rectal perforation, retroperitoneal sepsis, and pelvic sepsis 1

Clinical decision: For grade III hemorrhoids, rubber band ligation causes less postoperative pain and fewer complications than excisional hemorrhoidectomy, but has higher recurrence rate 5. For grade IV hemorrhoids, excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended 5.

Procedures to Avoid

• Anal dilatation should be completely abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1, 4, 3
• Cryotherapy causes prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 3
• Simple incision and drainage of thrombosed hemorrhoids leads to persistent bleeding and higher recurrence rates 1, 3

Management of Thrombosed External Hemorrhoids

Timing determines treatment approach:

Early Presentation (Within 72 Hours)

Complete excision under local anesthesia is recommended for thrombosed external hemorrhoids presenting within 72 hours, providing faster pain relief and reduced risk of recurrence. 1, 2

• Can be performed as outpatient procedure with low complication rates 1
• Superior to simple incision and drainage, which causes persistent bleeding and higher recurrence 1, 3

Late Presentation (>72 Hours)

Conservative management is preferred when presenting beyond 72 hours, as spontaneous resolution has begun: 1, 3

• Stool softeners 1, 2
• Oral and topical analgesics (5% lidocaine) 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1
• Warm sitz baths 1

Special Populations

Pregnant Patients

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents (psyllium husk), osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in third trimester with no adverse events 1
• Surgery deferred until postpartum unless tissue necrosis occurs 3

Immunocompromised Patients

• Increased risk of necrotizing pelvic sepsis after any hemorrhoid procedure 1, 3
• Require medical stabilization before surgical intervention 3
• Contraindication to rubber band ligation 1

Red Flags Requiring Emergency Evaluation

Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis—a rare but serious complication requiring emergency examination under anesthesia with radical debridement. 1, 3

Critical Diagnostic Considerations

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) 1
• Anal pain is generally not associated with uncomplicated internal hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids) 1
• Complete colonic evaluation by colonoscopy is indicated when bleeding is atypical, no source is evident on anorectal examination, or patient has significant risk factors for colonic neoplasia 1