What is the best treatment approach for a patient presenting with hemorrhoids?

Management of Hemorrhoids

Begin 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 severity. 1, 2

Initial Assessment

• Perform digital rectal examination and anoscopy (when tolerable) to confirm diagnosis and rule out other anorectal pathology such as anal fissures, abscesses, or malignancy 1, 2
• Check vital signs, complete blood count, and coagulation parameters if significant bleeding is present 2
• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to exclude proximal colonic pathology—hemorrhoids alone do not cause positive guaiac tests 1
• Recognize that anal pain suggests complications (thrombosis, fissure) rather than uncomplicated hemorrhoids 1

Conservative Management (First-Line for All Grades)

• Increase dietary fiber to 25-30g daily using psyllium husk (5-6 teaspoonfuls with 600mL water daily) to soften stool and reduce straining 1, 2
• Ensure adequate fluid intake throughout the day 1, 2
• Advise patients to avoid prolonged straining and sitting on the toilet 1
• Recommend warm sitz baths to reduce inflammation and discomfort 1

Pharmacological Management

For Symptomatic Relief

• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks—this achieves 92% resolution rate compared to 45.8% with lidocaine alone 1, 2
• Use topical corticosteroids for perianal inflammation, but limit to ≤7 days maximum to prevent mucosal thinning 1, 2
• Consider phlebotonics (flavonoids) for bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 3

Topical Alternatives

• Topical nitrates provide good results but are limited by high incidence of headache (up to 50%) 1
• Topical heparin shows promise for healing but evidence remains limited 1

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

When to Proceed

• Implement office procedures when conservative management fails after 1-2 weeks or symptoms persist 1
• Rubber band ligation is the most effective office-based procedure with 70-89% success rates and should be first-line procedural treatment 1, 2, 3

Rubber Band Ligation Technique

• Place bands at least 2cm proximal to dentate line to avoid severe pain 1
• Treat 1-2 hemorrhoid columns per session (maximum 3) 1
• Expect minor pain in 5-60% of patients, manageable with sitz baths and over-the-counter analgesics 1
• Avoid in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic sepsis 1

Alternative Office Procedures

• Sclerotherapy for grade I-II hemorrhoids achieves 70-85% short-term success but only one-third achieve long-term remission 1, 3
• Infrared photocoagulation has 67-96% success for grade I-II hemorrhoids but requires more repeat treatments 1

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

Within 72 hours of symptom onset:

• Perform complete excision under local anesthesia in office/clinic setting—this provides faster pain relief and lower recurrence rates 1, 2, 3
• Never perform simple incision and drainage—this causes persistent bleeding and higher recurrence 1

Beyond 72 hours:

• Conservative management is preferred as natural resolution has begun 1, 2
• Apply topical 0.3% nifedipine with 1.5% lidocaine every 12 hours for two weeks 1, 2
• Use stool softeners and oral analgesics (acetaminophen or ibuprofen) 1
• Topical corticosteroids for ≤7 days only 1

Surgical Management

Indications for Hemorrhoidectomy

• Failure of conservative and office-based therapies 1, 2
• Symptomatic grade III-IV hemorrhoids 1, 2
• Mixed internal and external hemorrhoids 1, 2
• Anemia from hemorrhoidal bleeding—this represents critical threshold requiring definitive intervention 1
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 1

Surgical Approach

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is most effective with 2-10% recurrence rate 1, 2, 3
• Ferguson closed technique reduces postoperative pain and improves wound healing compared to open technique 1
• Expect 2-4 weeks before return to work due to postoperative pain requiring narcotic analgesics 1
• Stapled hemorrhoidopexy shows less postoperative pain but lacks long-term efficacy data and has higher recurrence rates 1, 4

Procedures to Avoid

• Never perform anal dilatation—52% incontinence rate at 17-year follow-up 1
• Avoid cryotherapy due to prolonged pain, foul discharge, and need for additional therapy 1

Special Populations

Pregnancy

• Hemorrhoids occur in 80% of pregnant persons, most commonly third trimester 1, 5
• Safe treatments include dietary fiber, adequate fluids, psyllium husk, and osmotic laxatives (polyethylene glycol, lactulose) 1, 5
• Hydrocortisone foam is safe in third trimester with no adverse events in prospective study of 204 patients 1, 5
• Avoid stimulant laxatives due to conflicting safety data 5
• Approximately 0.2% require urgent hemorrhoidectomy for incarcerated prolapsed hemorrhoids 5

Critical Pitfalls to Avoid

• Never assume all anorectal symptoms are hemorrhoids—anal fissures coexist in up to 20% of patients 1, 2
• Never attribute anemia to hemorrhoids without colonoscopy—anemia from hemorrhoids is rare (0.5 per 100,000 population) 1
• Never use corticosteroids >7 days—causes perianal mucosal thinning and increased injury risk 1, 2
• Recognize necrotizing pelvic sepsis (rare but serious): severe pain, high fever, urinary retention require emergency evaluation 1
• In patients with cirrhosis or portal hypertension, consider anorectal varices rather than hemorrhoids—standard hemorrhoidectomy can cause life-threatening bleeding 1

Follow-Up

• Reassess within 1-2 weeks if symptoms worsen, fail to improve, or if significant bleeding, severe pain, or fever develop 1
• Expect minimal spotting after hemorrhoidectomy resolving within 7-14 days 1
• Signs requiring immediate evaluation post-hemorrhoidectomy: hemodynamic instability, anemia symptoms, or persistent heavy bleeding 1