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

Treatment of Hemorrhoids

First-Line Conservative Management for All Grades

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

• Dietary fiber supplementation with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL water daily effectively 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 fecal occult blood or anemia to hemorrhoids without complete colonic evaluation by colonoscopy, as hemorrhoids alone do not cause positive stool guaiac tests 1, 2
• 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 hemorrhoid patients) 1

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Topical 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 compared to only 45.8% with lidocaine alone. 1, 2, 4

• This combination works by relaxing internal anal sphincter hypertonicity without 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, 2, 4
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1
• Over-the-counter suppositories provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

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Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails. 1, 2, 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 additional treatments than infrared photocoagulation 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 prefer 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients) but is typically manageable with sitz baths and over-the-counter analgesics 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1

Alternative Office Procedures (Less Effective)

• Sclerotherapy: suitable for grade I-II hemorrhoids with 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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Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

For presentation within 72 hours of symptom onset: Complete surgical excision under local anesthesia is preferred, providing faster pain relief and lower recurrence rates. 1, 2, 4, 3

• Excision can be performed as an outpatient procedure with low complication rates 1
• Never perform simple incision and drainage alone—this leads to persistent bleeding and higher recurrence rates 1, 4

For presentation >72 hours after onset: Conservative management is preferred as natural resolution has begun. 1, 4

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1, 4
• Stool softeners, oral analgesics (acetaminophen or ibuprofen), and topical 5% lidocaine 1, 3
• Flavonoids for symptom relief 4
• Short-term topical corticosteroids (≤7 days only) 4

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Surgical Hemorrhoidectomy Indications

Conventional excisional hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and hemorrhoids causing anemia. 1, 2

Surgical Approach

• Closed Ferguson technique is superior to open Milligan-Morgan with reduced postoperative pain and faster wound healing 1, 5
• Recurrence rate is only 2-10%, the lowest of all treatment modalities 1, 2, 3
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Specific Indications

• Hemorrhoids causing anemia: Hemorrhoidectomy provides definitive treatment when active bleeding has caused significant blood loss 1
• Grade IV hemorrhoids: Conventional excisional hemorrhoidectomy is the gold standard 1
• Mixed internal and external hemorrhoids with symptomatic external component 1
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids 1

Procedures to Avoid

• Anal dilatation should never be performed—52% incontinence rate at 17-year follow-up 1, 5
• Cryotherapy should be avoided—prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

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Special Populations

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 with no adverse events 1

Patients with Anemia

• Never delay definitive treatment when active bleeding has caused anemia—hemorrhoidectomy is indicated 1
• Blood transfusion may be needed preoperatively if hemodynamically unstable 1
• Colonoscopy must be performed to rule out proximal colonic pathology 1

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Red Flags Requiring Urgent Evaluation

• Severe pain, high fever, and urinary retention suggest necrotizing pelvic sepsis (rare but serious complication requiring emergency evaluation) 1
• Significant bleeding with hemodynamic instability requires checking vital signs, complete blood count, and blood type/crossmatch 1, 2
• If symptoms worsen or fail to improve within 1-2 weeks of treatment, reassessment is necessary 1, 4