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

Treatment of Hemorrhoids

Begin with conservative management for all hemorrhoid grades, including increased dietary fiber (25-30g daily) and water intake, combined with topical treatments for symptom relief; escalate to rubber band ligation for persistent grade I-III internal hemorrhoids, and reserve surgical hemorrhoidectomy for grade III-IV disease or when less invasive approaches fail. 1, 2

Initial Assessment and Classification

• Perform digital rectal examination and anoscopy when tolerable to assess hemorrhoid grade and rule out other anorectal pathology such as fissures, abscesses, or malignancy 1, 2
• Check vital signs, complete blood count (hemoglobin/hematocrit), and coagulation parameters if significant bleeding is present 2
• Internal hemorrhoids are graded I-IV: Grade I bleeds without prolapse, Grade II prolapses with spontaneous reduction, Grade III requires manual reduction, and Grade IV is irreducible 1, 3
• External hemorrhoids cause symptoms primarily when thrombosed, presenting with acute anal pain and a palpable perianal lump 1, 4
• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to exclude inflammatory bowel disease or colorectal cancer 1, 2, 4

Conservative Management (First-Line for All Grades)

• Increase dietary fiber to 25-30 grams daily using psyllium husk (5-6 teaspoonfuls with 600mL water daily) to soften stool and reduce straining 1, 2, 3
• Ensure adequate water intake and avoid prolonged straining during defecation 1, 2
• Prescribe phlebotonics (flavonoids) to relieve bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 3
• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks, achieving 92% resolution rate compared to 45.8% with lidocaine alone 1, 2, 4
• Use topical corticosteroids for perianal inflammation for no more than 7 days to avoid thinning of perianal and anal mucosa 1, 2, 4
• Recommend warm sitz baths to reduce inflammation and discomfort 1

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

Rubber band ligation is the most effective office-based procedure and should be first-line procedural treatment when conservative management fails after 1-2 weeks. 1, 2, 3

• Rubber band ligation achieves 70.5-89% success rates depending on hemorrhoid grade and is more effective than sclerotherapy or infrared photocoagulation 1, 3
• Place bands at least 2cm proximal to the dentate line to avoid severe pain from somatic nerve stimulation 1
• Treat 1-2 hemorrhoid columns per session (up to 3 maximum) to minimize complications 1
• Pain occurs in 5-60% of patients but is typically manageable with sitz baths and over-the-counter analgesics 1
• Severe bleeding may occur when the eschar sloughs 1-2 weeks post-procedure 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic sepsis 1
• Recent evidence suggests rubber band ligation with local anesthesia injection may be effective even for symptomatic non-thrombosed external hemorrhoids, with 90% patient satisfaction 5

Alternative Office Procedures

• Sclerotherapy is suitable for grade I-II hemorrhoids with 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, 3
• Bipolar diathermy achieves 88-100% bleeding control for grade II hemorrhoids 1

Management of Thrombosed External Hemorrhoids

Within 72 Hours of Symptom Onset

Perform complete surgical excision under local anesthesia for faster symptom resolution and lower recurrence rates. 1, 2, 4, 3

• Excision provides more rapid pain relief than conservative management 1, 4
• Never perform simple incision and drainage as this leads to persistent bleeding and higher recurrence rates 1, 4

Beyond 72 Hours of Symptom Onset

Conservative management is preferred as natural resolution has begun. 1, 4, 3

• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1, 4
• Prescribe stool softeners and oral analgesics (acetaminophen or ibuprofen) 1, 3
• Use topical muscle relaxants for additional pain relief with severe sphincter spasm 1, 4
• Reassess if symptoms worsen or fail to improve within 1-2 weeks 1, 4

Surgical Management

Conventional excisional hemorrhoidectomy is indicated for grade III-IV hemorrhoids, failure of medical and office-based therapy, mixed internal/external hemorrhoids, or when concomitant anorectal conditions require surgery. 1, 2, 3

• Hemorrhoidectomy achieves 90-98% success rates with only 2-10% recurrence 1, 2, 3
• Ferguson (closed) technique may offer slightly improved wound healing compared to Milligan-Morgan (open) technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks 1
• Complications include urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%) 1
• Stapled hemorrhoidopexy shows less postoperative pain and faster recovery but higher recurrence rates and lacks long-term follow-up data 1, 6

Procedures to Avoid

• Never perform anal dilatation due to 52% incontinence rate at 17-year follow-up 1, 6
• Avoid cryotherapy due to prolonged pain, foul-smelling discharge, and need for additional therapy 1, 6

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in third trimester 1
• Safe treatments include dietary fiber, adequate fluids, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in third trimester with no adverse events 1

Patients with Anemia

Hemorrhoidectomy is indicated when hemorrhoidal bleeding causes anemia, as this represents substantial chronic blood loss requiring definitive control. 1

• Anemia from hemorrhoids is rare (0.5 patients per 100,000 population) 1
• Always perform colonoscopy to rule out proximal colonic pathology before attributing anemia to hemorrhoids 1
• Consider blood transfusion preoperatively if hemodynamically unstable or hemoglobin critically low 1

Critical Pitfalls to Avoid

• Do not assume all anorectal symptoms are hemorrhoids – anal fissures occur in up to 20% of patients with hemorrhoids 1
• Anal pain is NOT typical of uncomplicated hemorrhoids and suggests other pathology such as fissure, abscess, or thrombosis 1
• Never use corticosteroid creams for more than 7 days to prevent perianal tissue thinning 1, 2, 4
• Avoid office procedures for acutely thrombosed or irreducible hemorrhoids 1
• Patients with portal hypertension or cirrhosis may have anorectal varices rather than true hemorrhoids – standard hemorrhoidectomy can cause life-threatening bleeding in this population 1