What is the best treatment approach for an adult patient with hemorrhoids?

Treatment of Hemorrhoids

First-Line Conservative Management for All Patients

All patients with hemorrhoids should begin with dietary and lifestyle modifications, regardless of grade or severity. 1, 2

• Increase dietary fiber to 25-30 grams daily through diet or supplementation (psyllium husk 5-6 teaspoonfuls with 600 mL water daily), which has the strongest evidence for reducing bleeding and is the cornerstone of initial management 1, 2
• Increase water intake to soften stool and reduce straining during defecation 1, 2
• Avoid straining during bowel movements, which is the primary modifiable risk factor 1

Pharmacological Adjuncts to Conservative Management

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling through improvement of venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2, 3
• Topical analgesics (lidocaine 1.5-2%) provide symptomatic relief of local pain and itching 1
• Short-term topical corticosteroids (≤7 days maximum) may reduce local perianal inflammation, but prolonged use causes thinning of perianal and anal mucosa 1, 2

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 grade I-III internal hemorrhoids. 1, 3

Rubber Band Ligation (Preferred)

• Success rates of 70.5-89% depending on hemorrhoid grade 1, 3
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• 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 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic sepsis 1

Alternative Office Procedures (When Rubber Band Ligation Fails or Is Contraindicated)

• Sclerotherapy: 70-85% short-term success for grade I-II hemorrhoids, 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

Surgical Management

Excisional hemorrhoidectomy is indicated for grade III-IV hemorrhoids, failure of conservative and office-based therapy, mixed internal/external hemorrhoids, or when hemorrhoidal bleeding has caused anemia. 1, 3

Indications for Surgery

• Symptomatic grade III or IV hemorrhoids 1
• Failure of medical and office-based therapy 1
• Mixed internal and external hemorrhoids 1
• Anemia from hemorrhoidal bleeding 1
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids 1

Surgical Outcomes

• Recurrence rate of only 2-10%, making it the most definitive treatment 1, 3
• Closed Ferguson technique appears superior to open Milligan-Morgan regarding postoperative pain and wound healing 1, 4
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Procedures to Avoid

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

Management of Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours, complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates. 1, 3

Early Presentation (Within 72 Hours)

• Complete excision under local anesthesia as outpatient procedure provides fastest symptom resolution and lowest recurrence 1, 3
• Never perform simple incision and drainage, which leads to persistent bleeding and higher recurrence rates 1

Late Presentation (Beyond 72 Hours)

• Conservative management is preferred as natural resolution has typically begun 1, 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone 1, 2
• No systemic side effects observed with topical nifedipine 1
• Stool softeners and oral analgesics (acetaminophen or ibuprofen) 1, 3

Special Populations

Pregnancy

• 80% of pregnant persons develop hemorrhoids, most commonly in third trimester 1, 5
• Safe treatments include dietary fiber (30 g/day), adequate fluids, and bulk-forming agents like psyllium husk 1, 5
• Osmotic laxatives (polyethylene glycol or lactulose) are safe during pregnancy 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

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1, 2
• Never use corticosteroid creams for more than 7 days due to risk of perianal tissue thinning 1, 2
• Do not delay definitive treatment when active bleeding has caused anemia, as continued blood loss will occur 1, 2
• Avoid assuming all anorectal symptoms are due to hemorrhoids, as anal fissures coexist in up to 20% of patients 1
• Anal pain is generally NOT associated with uncomplicated internal hemorrhoids; its presence suggests other pathology such as fissure, abscess, or thrombosis 1
• In patients with cirrhosis or portal hypertension, consider anorectal varices rather than hemorrhoids, as standard hemorrhoidectomy can cause life-threatening bleeding 1