What pain reliever is recommended for a patient with hemorrhoids?

Pain Relief for Hemorrhoids

For symptomatic pain relief from hemorrhoids, use topical lidocaine (2-5% cream, ointment, or patches) combined with conservative measures, and for thrombosed external hemorrhoids specifically, topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours achieves 92% resolution compared to only 45.8% with lidocaine alone. 1

Topical Analgesic Options

First-Line: Lidocaine Formulations

• Topical lidocaine (2-5% formulations) provides symptomatic relief of local pain and itching associated with hemorrhoids 1
• Lidocaine patches (4% over-the-counter or 5% prescription strength) may be more effective than cream or ointment because they deliver lidocaine gradually over 12-24 hours, with most patients reporting improvement in pain 1
• Apply lidocaine cream, ointment, or patches directly to affected areas as needed for pain relief 1

Enhanced Option: Combination Therapy for Thrombosed Hemorrhoids

• Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks shows a 92% resolution rate, compared to only 45.8% with lidocaine alone 1, 2
• This combination works by relaxing internal anal sphincter hypertonicity which contributes to pain, with no systemic side effects observed 3, 2
• This is the preferred pharmacological option for thrombosed external hemorrhoids presenting after 72 hours 1

Oral Analgesics

• Over-the-counter oral analgesics (acetaminophen or ibuprofen) provide additional pain control beyond topical therapy 3
• Postoperative pain from excisional hemorrhoidectomy can be treated with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics 4

Alternative Topical Agents (Less Preferred)

• Topical nitrates show good results for pain relief but have a high incidence of headache (up to 50%) that may limit their use 3, 2
• Topical heparin treatment has shown promise in improving healing and resolution, though evidence is limited to small studies 3, 2
• Tribenoside + lidocaine combination (tribenoside 5%/lidocaine 2% cream or 400mg/40mg suppository) provides rapid comprehensive efficacy on hemorrhoidal symptoms with fast onset from 10 minutes after administration, lasting 10-12 hours 5

Corticosteroids: Use With Extreme Caution

• Corticosteroid creams may ameliorate local perianal inflammation but should be applied for NO MORE than 7 days 1, 3, 2
• Long-term use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 3
• Avoid high-potency corticosteroid suppositories for long-term use as they are potentially harmful 3

Essential Adjunctive Conservative Measures

• All patients should receive increased dietary fiber (5-6 teaspoonfuls psyllium husk with 600 mL water daily), adequate fluid intake to soften stool, and avoidance of straining during defecation 1, 6
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1, 3
• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 3, 6

Treatment Algorithm Based on Hemorrhoid Type and Timing

For Thrombosed External Hemorrhoids Within 72 Hours

• Surgical excision under local anesthesia is preferred for faster pain relief and reduced recurrence risk 1, 2
• Simple incision and drainage is NOT recommended due to persistent bleeding and higher recurrence rates 3, 2

For Thrombosed External Hemorrhoids After 72 Hours

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for 2 weeks is first-line pharmacological treatment (92% resolution rate) 1, 2
• Conservative management is preferred as natural resolution has typically begun 2

For Non-Thrombosed Internal or External Hemorrhoids

• Start with topical lidocaine (2-5%) for symptomatic pain relief 1
• Add oral analgesics (acetaminophen or ibuprofen) as needed 3
• Consider short-term corticosteroids (≤7 days only) if significant inflammation present 1, 3

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days—prolonged use causes perianal and anal mucosa thinning 1, 3, 2
• Do not rely on suppository medications alone, as they lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 3
• Avoid attributing severe pain to uncomplicated hemorrhoids—severe pain suggests thrombosis or other pathology like anal fissure 3
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is necessary 3, 2