What are the treatment options for an adult patient with hemorrhoids?

Treatment of Hemorrhoids

First-Line Conservative Management for All Hemorrhoid Grades

All patients with hemorrhoids should begin with conservative management consisting of increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining during defecation. 1, 2

• Dietary fiber supplementation with psyllium husk (5-6 teaspoonfuls with 600 mL water daily) prevents progression and reduces bleeding episodes 2
• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1

Critical Diagnostic Pitfall

• Never attribute rectal bleeding or anemia to hemorrhoids without proper colonic evaluation—colonoscopy is mandatory to exclude colorectal cancer or inflammatory bowel disease 1, 2
• Hemorrhoids alone do not cause positive fecal occult blood tests 1
• Anal pain suggests other pathology (fissure, abscess, thrombosis) rather than uncomplicated hemorrhoids 1

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Topical Pharmacological Management

For Non-Thrombosed Hemorrhoids

• Topical lidocaine (1.5-2% ointment) provides symptomatic relief of pain and itching, though long-term efficacy data are limited 1, 4
• Topical corticosteroids reduce perianal inflammation but must be limited to ≤7 days maximum to prevent thinning of perianal and anal mucosa 1, 2, 4

For Thrombosed External Hemorrhoids

• Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone 1, 2
• No systemic side effects occur with topical nifedipine 1
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1, 4
• Topical heparin significantly improves healing, though evidence is limited to small studies 1, 4

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Office-Based Procedures for Grade I-III Internal Hemorrhoids

When conservative management fails after 1-2 weeks, rubber band ligation is the first-line procedural intervention for persistent grade I-III internal hemorrhoids. 1, 3

Rubber Band Ligation

• Success rates range from 70.5% to 89% depending on hemorrhoid grade 1, 2
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can be performed in office without anesthesia 1
• The 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 1

Common complications:

• Pain (5-60% of patients) is typically minor and manageable with sitz baths and over-the-counter analgesics 1
• Band slippage, prolapse/thrombosis of adjacent hemorrhoids (~5%) 1
• Severe bleeding when eschar sloughs (1-2 weeks post-treatment) 1
• Contraindicated in immunocompromised patients due to risk of necrotizing pelvic sepsis 1

Alternative Office Procedures

• Sclerotherapy: suitable for grade I-II hemorrhoids, 70-85% short-term efficacy but only one-third achieve long-term remission 1, 3
• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids, but requires more repeat treatments 1, 3
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

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Surgical Management

Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) is indicated for:

• Failure of conservative and office-based therapy 1, 2
• Symptomatic grade III-IV hemorrhoids 1, 3
• Mixed internal and external hemorrhoids 1
• Hemorrhoids causing anemia from chronic bleeding 1
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 1

Surgical Outcomes

• Hemorrhoidectomy is the most effective treatment overall with lowest recurrence rate (2-10%), particularly for grade III-IV hemorrhoids 1, 2, 3
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Ferguson (closed) technique may have reduced postoperative pain compared to Milligan-Morgan (open) technique 1

Procedures to Avoid

• Anal dilatation should never be performed—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

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Management of Thrombosed External Hemorrhoids

Presentation Within 72 Hours

Complete surgical excision under local anesthesia as an outpatient procedure is the treatment of choice, providing faster pain relief and lower recurrence rates compared to conservative management. 1, 2, 3

• Never perform simple incision and drainage—this leads to persistent bleeding and significantly higher recurrence rates 1, 2

Presentation After 72 Hours

Conservative management is preferred when natural resolution has begun, consisting of:

• Stool softeners 1, 3
• Oral analgesics (acetaminophen or ibuprofen) 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1, 2
• Topical muscle relaxants for severe sphincter spasm 1, 4

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Treatment Algorithm Based on Hemorrhoid Grade

Grade I (bleeding, no prolapse):

1. Conservative management (fiber, fluids, lifestyle modification) 1, 2
2. If persistent: rubber band ligation or sclerotherapy 1, 3

Grade II (prolapse with spontaneous reduction):

1. Conservative management 1, 2
2. If persistent: rubber band ligation (first choice) 1, 3
3. Alternative: infrared photocoagulation or sclerotherapy 1

Grade III (prolapse requiring manual reduction):

1. Conservative management trial 1, 2
2. Rubber band ligation for persistent symptoms 1, 3
3. Hemorrhoidectomy if office procedures fail or patient preference 1, 3

Grade IV (irreducible prolapse):

1. Surgical hemorrhoidectomy is first-line treatment 1, 3
2. Conservative management only for patients unfit for surgery 1

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Special Considerations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in third trimester 1
• Safe treatments: dietary fiber, adequate fluids, psyllium husk, osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in third trimester 1

Anemia from Hemorrhoidal Bleeding

• Hemorrhoidectomy is indicated when hemorrhoids cause anemia, as this represents substantial chronic blood loss requiring definitive control 1
• Blood transfusion may be needed preoperatively if hemodynamically unstable 1
• Always perform colonoscopy to rule out proximal colonic pathology before attributing anemia to hemorrhoids 1