What are the treatment options for a patient with hemorrhoids (piles)?

Treatment of Hemorrhoids

Start all patients with conservative management—increased dietary fiber (25-30g daily, ideally 5-6 teaspoonfuls psyllium husk with 600mL water), adequate hydration, and avoidance of straining—which serves as first-line therapy regardless of hemorrhoid grade. 1, 2

Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications:

• Increase fiber intake to 25-30g daily using psyllium husk (5-6 teaspoonfuls with 600mL water daily) to soften stool and reduce straining 1, 3
• Ensure adequate water intake throughout the day 1, 2
• Implement the "TONE" method: Three minutes at defecation, Once-daily bowel movements, No straining, Enough fiber 3
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Options for Symptom Relief:

• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though 80% experience symptom recurrence within 3-6 months after cessation 1, 4
• Topical analgesics (lidocaine 1.5-2%) provide symptomatic relief of local pain and itching 1
• Short-term topical corticosteroids (≤7 days maximum) reduce perianal inflammation but must be limited to avoid tissue thinning 1, 2

Management of Thrombosed External Hemorrhoids

Timing determines treatment approach:

Within 72 hours of symptom onset:

• Complete surgical excision under local anesthesia provides fastest pain relief and lowest recurrence rates 1, 2, 4
• This can be performed as an outpatient procedure 1

Beyond 72 hours:

• Conservative management is preferred as natural resolution has typically begun 1, 4
• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate vs. 45.8% with lidocaine alone) 1, 2
• Use stool softeners and oral analgesics 1, 4

Critical pitfall: Never perform simple incision and drainage—this causes persistent bleeding and higher recurrence rates; complete excision is required if surgery is chosen 1, 2

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

When conservative management fails after 1-2 weeks:

Rubber band ligation is the preferred first procedural intervention:

• Success rates of 70.5-89% depending on hemorrhoid grade 1, 2, 4
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can treat up to 3 hemorrhoids per session, though many practitioners limit to 1-2 columns 1
• Band must be placed at least 2cm proximal to dentate line to avoid severe pain 1
• Repeated banding needed in up to 20% of patients 4

Alternative office procedures (less effective):

• Sclerotherapy: Suitable for grade I-II hemorrhoids, 70-85% short-term success but only one-third achieve long-term remission 1, 4
• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids, 70-80% success in reducing bleeding and prolapse 1, 4
• Bipolar diathermy: 88-100% success for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for hemorrhoidectomy:

• Failure of medical and office-based therapy 1, 2
• Symptomatic grade III-IV hemorrhoids 1, 2
• Mixed internal and external hemorrhoids 1, 2
• Hemorrhoids causing anemia 1
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 1

Conventional excisional hemorrhoidectomy (Milligan-Morgan or Ferguson technique):

• Most effective treatment overall with 2-10% recurrence rate 1, 2, 4
• Success rates approach 90-98% 1
• Major drawback: postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks 1
• Recovery typically 9-14 days 4

Procedures to avoid:

• Anal dilatation: 52% incontinence rate at 17-year follow-up—should be abandoned 1
• Cryotherapy: Causes prolonged pain, foul-smelling discharge, and requires more additional therapy 1

Special Considerations

Pregnancy:

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in third trimester 1, 5
• Safe treatments include dietary fiber, adequate fluids, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol or lactulose) 1, 5
• Hydrocortisone foam is safe in third trimester with no adverse events compared to placebo 1, 5
• Avoid stimulant laxatives due to conflicting safety data 5

Critical diagnostic pitfalls:

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood requires full colonic evaluation until proven otherwise 1, 2
• Anemia from hemorrhoids is rare (0.5 patients/100,000 population)—always investigate other causes 1
• Anal pain suggests other pathology (fissure, abscess, thrombosis) as uncomplicated internal hemorrhoids are typically painless 1
• Up to 20% of patients with hemorrhoids have coexisting anal fissures 1
• Perform colonoscopy if bleeding is atypical, no source evident on anorectal exam, or significant risk factors for colonic neoplasia present 1, 2