What is the best approach to managing hemorrhoids?

Management of Hemorrhoids

Begin with conservative management for all hemorrhoid grades, including increased fiber (25-30g daily) and water intake, combined with avoidance of straining during defecation, as this is first-line therapy regardless of hemorrhoid severity. 1, 2, 3

Initial Assessment

When evaluating hemorrhoids, perform the following:

• Check vital signs, hemoglobin, hematocrit, and coagulation parameters to assess bleeding severity, particularly if significant bleeding is present 1, 3
• Perform digital rectal examination to rule out other causes of lower gastrointestinal bleeding such as anal fissures (present in up to 20% of hemorrhoid patients), abscesses, or masses 1, 2
• Conduct anoscopy when feasible and well tolerated to visualize internal hemorrhoids and assess their grade 1, 2, 3
• Never attribute anemia or positive fecal occult blood to hemorrhoids alone without colonoscopy to rule out inflammatory bowel disease or colorectal cancer 2

Classification System

• Grade I: Bleeding without prolapse 2
• Grade II: Prolapse beyond anus with spontaneous reduction 2, 4
• Grade III: Prolapse requiring manual reduction 2, 4
• Grade IV: Irreducible prolapse 2, 4

Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications

• Increase dietary fiber to 25-30 grams daily using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1, 2, 3
• Increase water intake to maintain soft, bulky stools 1, 2, 3
• Avoid prolonged straining during defecation and limit time on toilet 1, 2, 3
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 2

Pharmacological Options

For all symptomatic hemorrhoids:

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2, 5, 4
• Topical lidocaine 1.5-2% ointment provides symptomatic relief of local pain and itching 2, 5

For thrombosed external hemorrhoids specifically:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone, with no systemic side effects 2, 3, 5
• Topical muscle relaxants provide additional pain relief, particularly with severe sphincter spasm 1, 5

Short-term adjuncts (≤7 days maximum):

• Topical corticosteroids may reduce local perianal inflammation but must be limited to 7 days or less to avoid thinning of perianal and anal mucosa 1, 2, 3, 5

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

When conservative management fails after 1-2 weeks, proceed to office-based procedures:

Rubber Band Ligation (First-Line Procedural Treatment)

• Most effective office-based procedure with success rates of 70.5-89% depending on hemorrhoid grade 2, 3, 4
• Place bands at least 2 cm proximal to dentate line to avoid severe pain from somatic nerve stimulation 2
• Treat 1-2 hemorrhoid columns per session (up to 3 maximum) 2
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 2
• Repeated banding needed in up to 20% of patients 4

Complications to monitor:

• Pain (5-60% of patients, typically minor and manageable with sitz baths and over-the-counter analgesics) 2
• Severe bleeding when eschar sloughs (typically 1-2 weeks post-treatment) 2
• Necrotizing pelvic sepsis (rare but serious; contraindicated in immunocompromised patients including those with uncontrolled AIDS, neutropenia, or severe diabetes) 2

Alternative Office Procedures

• Infrared photocoagulation: 67-96% success for Grade I-II hemorrhoids, but requires more repeat treatments 2
• Sclerotherapy: 70-85% short-term efficacy, but long-term remission in only one-third of patients 4
• Bipolar diathermy: 88-100% success for bleeding control in Grade II hemorrhoids 2

Management of Thrombosed External Hemorrhoids

Timing-Based Algorithm

Presentation within 72 hours of symptom onset:

• Complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management 1, 2, 3, 4
• Never perform simple incision and drainage as this leads to persistent bleeding and significantly higher recurrence rates 1, 2, 3

Presentation beyond 72 hours:

• Conservative management is preferred as natural resolution has typically begun 1, 2, 4
• Use topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 2, 3
• Add stool softeners and oral analgesics (acetaminophen or ibuprofen) 2, 4

Surgical Management

Indications for Hemorrhoidectomy

Proceed to surgical hemorrhoidectomy when:

• Failure of medical and office-based therapy 2, 3
• Symptomatic Grade III-IV hemorrhoids 2, 3, 4
• Mixed internal and external hemorrhoids 2, 3
• Hemorrhoids with anemia from chronic bleeding 2
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 2

Surgical Options

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall with lowest recurrence rate of 2-10%, particularly for Grade III-IV hemorrhoids 2, 3, 4
• Ferguson closed technique is associated with reduced postoperative pain and faster wound healing compared to open technique 2
• Major drawback: postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 2

Procedures to Avoid

• Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up and sphincter injuries 2
• Cryotherapy should be avoided due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 2

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to exclude proximal colonic pathology 2
• Anal pain is NOT typical of uncomplicated hemorrhoids; its presence suggests anal fissure, abscess, or thrombosis 2
• Never use corticosteroid creams for more than 7 days as prolonged use causes thinning of perianal and anal mucosa 1, 2, 3, 5
• Never perform simple incision and drainage of thrombosed hemorrhoids; complete excision is required if surgical intervention is chosen 1, 2, 3
• Patients with portal hypertension or cirrhosis may have anorectal varices rather than true hemorrhoids; standard hemorrhoidectomy can cause life-threatening bleeding in this population 2

Special Populations

Pregnant patients:

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in third trimester 2
• Safe treatments include dietary fiber, adequate fluid intake, psyllium husk, and osmotic laxatives (polyethylene glycol or lactulose) 2
• Hydrocortisone foam can be used safely in third trimester 2

Immunocompromised patients:

• Increased risk of necrotizing pelvic infection with rubber band ligation 2
• Consider alternative treatments or proceed with extreme caution 2