What are the treatment options for hemorrhoids?

Hemorrhoid Treatment

Start with conservative management for all hemorrhoid grades—increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining—as this is first-line therapy regardless of hemorrhoid type or severity. 1, 2

Conservative Management (First-Line for All Grades)

• Dietary modifications form the foundation: Consume 25-30 grams of fiber daily, achievable with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL water daily. 1, 2
• Increase water intake substantially to soften stool and reduce straining during defecation. 1, 2
• Avoid prolonged sitting on the toilet and straining, as these exacerbate hemorrhoidal symptoms. 1
• Sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief. 1

Pharmacological Management

For Symptomatic Relief

• Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution for thrombosed external hemorrhoids, compared to only 45.8% with lidocaine alone. 1, 2
• This combination works by relaxing internal anal sphincter hypertonicity (nifedipine) while providing local pain relief (lidocaine), with no systemic side effects observed. 1
• Topical lidocaine 1.5-2% ointment or cream provides symptomatic relief of pain and itching, though long-term efficacy data are limited. 1, 3

For Bleeding and Venous Tone

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation. 1, 3, 4

Corticosteroids (Use With Caution)

• Topical corticosteroid creams may reduce perianal inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa. 1, 2, 3
• Hydrocortisone foam can be used safely in pregnancy (third trimester) with no adverse events. 1

Alternative Topical Agents

• Topical nitrates show good results for thrombosed hemorrhoids but are limited by high incidence of headache (up to 50% of patients). 1, 3
• Topical heparin significantly improves healing of acute hemorrhoids, though evidence is limited to small studies. 1, 3

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

Rubber Band Ligation (Preferred First Procedural Intervention)

• Rubber band ligation is the most effective office-based procedure for grade I-III internal hemorrhoids, with success rates of 70.5-89%, and is more effective than sclerotherapy or infrared photocoagulation. 1, 2, 4
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerves are absent above this zone. 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
• Pain is the most common complication (5-60% of patients) but is typically minor and manageable with sitz baths and over-the-counter analgesics. 1
• Severe bleeding occasionally occurs when the eschar sloughs, typically 1-2 weeks after treatment. 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection. 1

Alternative Office Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, inducing fibrosis and tissue shrinkage, with 70-85% short-term efficacy but only one-third achieving long-term remission. 1, 4
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments than rubber band ligation. 1, 4
• Bipolar diathermy achieves 88-100% success for bleeding control in grade II hemorrhoids. 1

Surgical Management

Indications for Hemorrhoidectomy

• Surgical hemorrhoidectomy is indicated for: 1, 2
  • Failure of medical and office-based therapy
  • Symptomatic grade III-IV hemorrhoids
  • Mixed internal and external hemorrhoids
  • Anemia from hemorrhoidal bleeding
  • Concomitant anorectal conditions requiring surgery (fissure, fistula)

Surgical Techniques

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with low recurrence rates of 2-10%. 1, 2, 4
• Ferguson (closed) technique involves excising hemorrhoid components and closing wounds primarily, associated with reduced postoperative pain compared to Milligan-Morgan (open) technique. 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks. 1
• Stapled hemorrhoidopexy shows promising results with less postoperative pain and faster return to activities, but lacks long-term follow-up data and has reported complications including rectal perforation and pelvic sepsis. 1, 5

Procedures to Avoid

• Anal dilatation should NEVER be performed due to 52% incontinence rate at 17-year follow-up and sphincter injuries. 1
• Cryotherapy should be avoided due to prolonged pain, foul-smelling discharge, and greater need for additional therapy. 1

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

• For thrombosed external hemorrhoids presenting within 72 hours, complete excision under local anesthesia is preferred, providing faster pain relief and lower recurrence rates compared to conservative management. 1, 2, 4, 5
• This can be performed as an outpatient procedure with low complication rates. 1
• NEVER perform simple incision and drainage of the thrombus alone—this leads to persistent bleeding and higher recurrence rates. 1

Late Presentation (>72 Hours)

• For presentation beyond 72 hours, conservative management is preferred as natural resolution has begun. 1
• Treatment includes stool softeners, oral analgesics (acetaminophen or ibuprofen), and topical 0.3% nifedipine with 1.5% lidocaine ointment. 1, 4
• Topical muscle relaxants provide additional pain relief, particularly with severe sphincter spasm. 1, 3

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without proper evaluation—colonoscopy should be performed to rule out proximal colonic pathology. 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), abscess, or thrombosis. 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients per 100,000 population); if present with active bleeding, this demands definitive surgical intervention. 1
• Avoid office-based procedures (rubber band ligation, sclerotherapy) for acutely thrombosed or irreducible hemorrhoids. 1
• Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis (rare but serious complication) requiring emergency evaluation. 1

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant women, more commonly during the third trimester. 1
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, and osmotic laxatives (polyethylene glycol or lactulose). 1
• Hydrocortisone foam can be used safely in the third trimester. 1
• Most hemorrhoids can be treated conservatively during pregnancy, with definitive treatment delayed until after delivery. 6

Immunocompromised Patients

• Patients with uncontrolled diabetes, immunosuppressive medications, uncontrolled AIDS, or neutropenia have increased risk of necrotizing pelvic infection from hemorrhoid procedures. 1
• Exercise extreme caution with any procedural intervention in this population. 1

Treatment Algorithm Based on Grade

Grade I (Bleeding, No Prolapse)

1. Conservative management with fiber, water, lifestyle modifications 1, 2
2. If persistent: Rubber band ligation or injection sclerotherapy 1, 4

Grade II (Prolapse with Spontaneous Reduction)

1. Conservative management initially 1, 2
2. If persistent: Rubber band ligation (preferred) or infrared photocoagulation 1, 4

Grade III (Prolapse Requiring Manual Reduction)

1. Conservative management trial 1, 2
2. If persistent: Rubber band ligation 1, 4
3. If failed or recurrent: Surgical hemorrhoidectomy 1, 2

Grade IV (Irreducible Prolapse)

• Surgical hemorrhoidectomy is first-line treatment for grade IV hemorrhoids, with conventional excisional techniques achieving 2-10% recurrence rates. 1, 2, 4