What are the treatment options for a typical adult patient with hemorrhoids?

Treatment of Hemorrhoids

All hemorrhoid treatment should begin with conservative management consisting of increased dietary fiber (25-30 grams daily), adequate water intake, and avoidance of straining during defecation, regardless of hemorrhoid grade or severity. 1, 2

Conservative Management (First-Line for All Patients)

Dietary and lifestyle modifications form the foundation of hemorrhoid treatment and should be implemented in every patient before considering procedural interventions. 1

• Increase dietary fiber to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to produce soft, bulky stools 1, 3
• Ensure adequate water intake throughout the day to soften stool and reduce straining 1, 2
• Avoid prolonged straining during defecation, which exacerbates hemorrhoidal symptoms 1, 2
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Treatment

Flavonoids (phlebotonics) are the most effective pharmacological option for controlling acute bleeding in all grades of hemorrhoids, though symptom recurrence reaches 80% within 3-6 months after cessation. 2, 3, 4

For Internal Hemorrhoids (Bleeding/Discomfort):

• Flavonoids for bleeding control through improvement of venous tone 2, 3
• Topical analgesics (lidocaine 1.5-2%) for symptomatic relief of pain and itching, though long-term efficacy data are limited 1, 2

For External Hemorrhoids (Non-Thrombosed):

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks (92% resolution rate vs 45.8% with lidocaine alone) 1, 2
• Short-term topical corticosteroids (≤7 days maximum) for local perianal inflammation—never exceed 7 days due to risk of perianal tissue thinning 1, 2, 3

For Thrombosed External Hemorrhoids:

Timing determines treatment approach:

• Within 72 hours of onset: Complete surgical excision under local anesthesia provides fastest pain relief and lowest recurrence rates 1, 4
• Beyond 72 hours: Conservative management with topical 0.3% nifedipine/1.5% lidocaine every 12 hours for two weeks (92% resolution rate) 1, 2
• Topical muscle relaxants for additional pain relief, particularly with severe sphincter spasm 1, 2
• Stool softeners and oral analgesics (acetaminophen or ibuprofen) 1, 4

Critical pitfall: Never perform simple incision and drainage of thrombosed hemorrhoids—this leads to persistent bleeding and significantly higher recurrence rates. Complete excision is required if surgical intervention is chosen. 1

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

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention when conservative management fails, with success rates of 70.5-89%. 1, 4, 5

• Place bands at least 2 cm proximal to the dentate line to avoid severe pain 1
• Can treat 1-3 hemorrhoid columns per session, though many practitioners limit to 1-2 columns 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Repeated banding needed in up to 20% of patients 4

Alternative Office Procedures:

• Injection sclerotherapy: Suitable for first and second-degree hemorrhoids, 70-85% short-term efficacy but only one-third achieve long-term remission 1, 4, 5
• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, 70-80% success for bleeding/prolapse control 1, 5
• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 1

Contraindication: Avoid rubber band ligation in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection. 1

Surgical Management

Conventional excisional hemorrhoidectomy (Milligan-Morgan or Ferguson technique) is the most effective treatment overall with the lowest recurrence rate (2-10%) and should be performed for grade III-IV hemorrhoids, mixed internal/external disease, or failure of conservative and office-based therapies. 1, 4, 5

Indications for Hemorrhoidectomy:

• Failure of medical and office-based therapy 1
• Symptomatic grade III or IV hemorrhoids 1, 4
• Mixed internal and external hemorrhoids 1, 4
• Hemorrhoidal bleeding causing anemia 1
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 1

Surgical Technique Considerations:

• Ferguson (closed) technique may offer slightly improved wound healing compared to Milligan-Morgan (open) technique 1
• Major limitation is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Recovery typically 9-14 days 4

Techniques to absolutely 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

Treatment Algorithm Based on Hemorrhoid Grade

Grade I (Bleeding, No Prolapse):

1. Conservative management (fiber, fluids, lifestyle modifications) 1
2. Flavonoids for bleeding control 2, 3
3. If persistent: Rubber band ligation or sclerotherapy 1

Grade II (Prolapse with Spontaneous Reduction):

1. Conservative management 1
2. If persistent: Rubber band ligation (first choice) 1, 4
3. Alternative: Infrared photocoagulation or sclerotherapy 1

Grade III (Prolapse Requiring Manual Reduction):

1. Conservative management trial 1
2. Rubber band ligation for smaller lesions 1
3. Surgical hemorrhoidectomy for larger lesions or failed banding 1, 4

Grade IV (Irreducible Prolapse):

1. Conventional excisional hemorrhoidectomy 1, 4

Special Populations

Pregnancy:

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in third trimester 1
• Safe treatments: dietary fiber, adequate fluids, bulk-forming agents (psyllium husk) 1
• Osmotic laxatives (polyethylene glycol or lactulose) safe during pregnancy 1
• Hydrocortisone foam safe in third trimester with no adverse events 1
• Delay definitive treatment until after delivery 5

Critical Diagnostic Pitfalls

Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to rule out proximal colonic pathology—hemorrhoids alone do not cause positive stool guaiac tests. 1, 3

• Anemia from hemorrhoidal disease is rare (0.5 patients/100,000 population) 1
• Anal pain is generally NOT associated with uncomplicated hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids) 1
• Perform colonoscopy if bleeding is atypical, no source evident on anorectal examination, or patient has significant risk factors for colonic neoplasia 1
• Consider inflammatory bowel disease or cancer if concerning features present 1