What are the treatment options for a patient with external hemorrhoids?

Treatment of External Hemorrhoids

For non-thrombosed external hemorrhoids, start with conservative management including increased fiber (25-30 grams daily), adequate water intake, and topical nifedipine 0.3% with lidocaine 1.5% applied every 12 hours for two weeks, which achieves 92% resolution. 1

Initial Conservative Management (First-Line for All External Hemorrhoids)

All external hemorrhoids should initially be managed conservatively before considering procedural interventions. 1

• Increase dietary fiber to 25-30 grams daily (can use psyllium husk 5-6 teaspoonfuls with 600 mL water daily) 1
• Increase water intake to soften stool and reduce straining 1
• Avoid straining during defecation 1
• Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Topical Pharmacological Options

Topical nifedipine 0.3% with lidocaine 1.5% ointment is the most effective topical treatment, achieving 92% resolution compared to only 45.8% with lidocaine alone. 1

• Apply every 12 hours for two weeks 1
• Works by relaxing internal anal sphincter hypertonicity that contributes to pain 1
• No systemic side effects observed 1
• Lidocaine provides symptomatic relief of local pain and itching 1

Alternative topical agents (less effective or more side effects):

• Topical corticosteroids may reduce local inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1
• Topical nitrates show good results but are limited by high incidence of headache (up to 50% of patients) 1
• Topical heparin significantly improves healing, though evidence is limited to small studies 1

Oral 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, 2
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) for additional pain control 1

Management of Thrombosed External Hemorrhoids

The treatment approach depends critically on timing of presentation:

Early Presentation (Within 72 Hours of Symptom Onset)

Complete excision under local anesthesia is recommended, providing faster pain relief and reducing risk of recurrence. 1

• Can be performed as an outpatient procedure with low complication rates 1
• Complete excision is superior to simple incision and drainage 1
• Never perform simple incision and drainage alone—this leads to persistent bleeding and higher recurrence rates 1

Late Presentation (>72 Hours After Onset)

Conservative management is preferred, as the natural resolution process has typically begun. 1

• Stool softeners 1
• Oral analgesics 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1
• Topical muscle relaxants for additional pain relief, particularly with severe sphincter spasm 1
• Short-term topical corticosteroids (≤7 days) 1

Emerging Treatment Option: Rubber Band Ligation for External Hemorrhoids

A recent 2025 study suggests rubber band ligation combined with local anesthesia injection may be an alternative to hemorrhoidectomy for symptomatic non-thrombosed external hemorrhoids. 3

• In a cohort of 50 patients, 50% reported no post-procedure discomfort, 44% had mild pain managed with OTC analgesics 3
• ~90% were satisfied with the technique and would opt for the procedure again 3
• Lidocaine is injected into surrounding tissue to anesthetize the hemorrhoid prior to band ligation 3

However, this represents emerging evidence from a small cohort and is not yet standard practice. Traditional teaching has been that rubber band ligation should be avoided for external hemorrhoids due to intense pain from somatic nerve innervation below the dentate line. 3

Surgical Management

Surgical hemorrhoidectomy is indicated for:

• Failure of conservative and office-based therapy 1
• Mixed internal and external hemorrhoids with symptomatic external component 1
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids 1
• Concomitant anorectal conditions requiring surgery 1

Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) has the lowest recurrence rate (2-10%) but requires narcotic analgesics for postoperative pain, with most patients not returning to work for 2-4 weeks. 1

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days—prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1
• Never perform simple incision and drainage of thrombosed external hemorrhoids—this leads to persistent bleeding and higher recurrence rates 1
• Never attribute anemia or significant bleeding to external hemorrhoids without colonoscopy to rule out proximal colonic pathology 1
• Avoid anoscopy in awake patients with acute thrombosed hemorrhoids—excruciating pain typically requires proper sedation 1
• Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up 1
• Cryotherapy should be avoided due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

When to Escalate Care

• Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis (rare but serious complication) requiring emergency evaluation 1
• If symptoms worsen or fail to improve within 1-2 weeks of conservative treatment, reassessment is recommended 1
• Immunocompromised patients (uncontrolled diabetes, on immunosuppressive medications) have increased risk of complications and may require earlier surgical intervention 1