Management of External Hemorrhoids
For external hemorrhoids, begin immediately with conservative management including increased fiber (25-30g daily) and water intake, combined with topical 0.3% nifedipine/1.5% lidocaine ointment every 12 hours for two weeks, which achieves 92% resolution compared to 45.8% with lidocaine alone. 1
Initial Conservative Management (First-Line for All External Hemorrhoids)
All external hemorrhoids should start with non-operative management before considering any procedural intervention. 1, 2
Core Dietary and Lifestyle Modifications
- Increase fiber intake to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to produce soft, bulky stools 1
- Maintain adequate hydration with increased water intake throughout the day 1
- Avoid straining during defecation, as this is the primary exacerbating factor 2
Topical Pharmacological Therapy
The most effective topical treatment is 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks, which works by relaxing internal anal sphincter hypertonicity while providing immediate pain relief, with no systemic side effects observed 1, 2
Additional topical options include:
- Topical analgesics (lidocaine 1.5-2%) for symptomatic relief of local pain and itching 2
- Short-term topical corticosteroids (≤7 days ONLY) to reduce perianal inflammation—never exceed 7 days due to risk of perianal tissue thinning 1, 2
- Topical nitrates show good results but are limited by high incidence of headache (up to 50% of patients) 2
- Topical heparin may improve healing, though evidence is limited to small studies 2
Systemic Pharmacological Therapy
- Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3
- Over-the-counter oral analgesics (acetaminophen or ibuprofen) for additional pain control 2
Non-Pharmacologic Adjuncts
- Regular sitz baths (warm water soaks) reduce inflammation and discomfort 2
Management of Thrombosed External Hemorrhoids
The management algorithm depends critically on timing of presentation:
Presenting Within 72 Hours of Symptom Onset
Surgical excision under local anesthesia is recommended, as it provides:
- Faster pain relief (3.9 days vs. 24 days with conservative management) 4
- Lower recurrence rate (6.3% vs. 25.4% with conservative management) 4
- Longer time to recurrence if it occurs (25 months vs. 7.1 months) 4
Presenting After 72 Hours of Symptom Onset
Conservative management is preferred, as the natural resolution process has typically begun 1, 2:
- Continue all conservative measures listed above
- Apply topical 0.3% nifedipine/1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1, 2
- Add stool softeners and oral analgesics 3
- Topical corticosteroids for ≤7 days only 1
Critical Pitfalls to Avoid
Never perform simple incision and drainage of thrombosed external hemorrhoids—this leads to persistent bleeding and significantly higher recurrence rates compared to complete excision 1, 2, 4
Never use topical corticosteroids for more than 7 days, as prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 2
Do not rely on suppositories as primary treatment—they provide only symptomatic relief with no strong evidence for reducing hemorrhoidal swelling or bleeding 2
Avoid attributing severe anal pain to uncomplicated external hemorrhoids without thrombosis—severe pain suggests thrombosed hemorrhoids, anal fissure (present in up to 20% of hemorrhoid patients), perianal abscess, or other pathology requiring different management 2, 5
Never attribute anemia or positive fecal occult blood to hemorrhoids without proper colonic evaluation, as anemia from hemorrhoids is rare (0.5 patients/100,000 population) and requires colonoscopy to rule out other pathology 2
When Conservative Management Fails
If symptoms worsen or fail to improve within 1-2 weeks of conservative treatment, reassessment is necessary 1
For persistent symptomatic external hemorrhoids after conservative management:
- Surgical excision provides the most rapid and persistent relief of symptoms for external hemorrhoidal disease 6
- Recent evidence suggests rubber band ligation with local anesthesia injection may be an alternative to hemorrhoidectomy for symptomatic non-thrombosed external hemorrhoids, with ~90% patient satisfaction and 50% reporting no post-procedure discomfort 7
Special Considerations
External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 2
Anoscopy may be impossible in awake patients with acutely thrombosed hemorrhoids due to excruciating pain and typically requires proper sedation 2
For mixed internal and external hemorrhoids, surgical hemorrhoidectomy may be required if conservative and office-based therapy fails 2