How to manage a patient with hemorrhoids and constipation?

Management of Hemorrhoids with Constipation

Treat both conditions simultaneously with high-fiber intake (25-30 grams daily), increased water intake, topical 0.3% nifedipine plus 1.5% lidocaine ointment every 12 hours for two weeks, and avoidance of straining during defecation. 1

First-Line Conservative Management

The cornerstone of managing hemorrhoids with constipation is addressing the underlying bowel dysfunction while providing symptomatic relief for the hemorrhoids. This dual approach prevents the cycle of straining that perpetuates both conditions.

Dietary and Lifestyle Modifications

• Increase fiber intake to 25-30 grams daily, which can be achieved using psyllium husk 5-6 teaspoonfuls with 600 mL water daily 1
• Substantially increase water intake to soften stool and reduce straining 1
• Avoid straining during defecation, as this is the primary mechanical factor worsening both hemorrhoids and constipation 1

The evidence supporting this approach is robust: when combined with topical therapy, dietary modifications achieve 92% symptom resolution 1. Importantly, functional constipation and dyssynergic defecation are significantly more prevalent in patients with hemorrhoids compared to controls (OR 2.09,95% CI 1.27-3.44) 2, making constipation management essential rather than optional.

Topical Pharmacological Treatment

• Apply topical 0.3% nifedipine combined with 1.5% lidocaine ointment every 12 hours for two weeks 1

  • This combination achieves 92% resolution rate compared to only 45.8% with lidocaine alone 1
  • Nifedipine relaxes internal anal sphincter hypertonicity, which contributes to pain 3
  • Lidocaine provides symptomatic relief of local pain and itching 3
  • No systemic side effects have been observed with topical nifedipine 1

• Topical corticosteroids (such as hydrocortisone) may reduce local perianal inflammation, but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 3

Oral Pharmacological Treatment

• Oral analgesics such as over-the-counter acetaminophen or ibuprofen can be used for additional pain control 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling through improvement of venous tone, but have a major limitation of 80% symptom recurrence within 3-6 months after cessation 1

Critical Monitoring and Warning Signs

Stop fiber supplementation and seek immediate evaluation if: 4

• Constipation lasts more than 7 days despite treatment
• Rectal bleeding occurs or worsens
• You fail to have a bowel movement after 7 days

These may indicate serious underlying conditions requiring colonoscopy or other evaluation 4.

When Conservative Management Fails

If symptoms worsen or fail to improve within 1-2 weeks of conservative treatment, further evaluation is necessary 3. The presence of significant bleeding, severe pain, or fever warrants immediate reassessment 3.

Office-Based Procedures for Persistent Hemorrhoids

• Rubber band ligation is the most effective office-based procedure for first to third-degree hemorrhoids, with success rates up to 89% 3, 5
• This should be considered only after adequate trial of conservative management and resolution of constipation 3

Surgical Management Indications

Surgery is indicated for: 3

• Failure of medical and non-operative therapy
• Symptomatic third or fourth-degree hemorrhoids
• Mixed internal and external hemorrhoids
• Complications such as thrombosis or strangulation

Conventional excisional hemorrhoidectomy remains the most effective treatment overall, particularly for third-degree hemorrhoids, with recurrence rates of only 2-10% 3.

Special Considerations for Constipation in Hemorrhoid Patients

The relationship between constipation and hemorrhoids is bidirectional and clinically significant. Anal pressures in patients with hemorrhoids are significantly higher compared to healthy controls, and these elevated pressures persist even after hemorrhoid treatment 2. This suggests that addressing dyssynergic defecation patterns is crucial for preventing hemorrhoid recurrence 2.

Improvement of therapy for functional constipation, especially dyssynergic defecation patterns, leads to better long-term outcomes and reduced recurrence 2.

Critical Pitfalls to Avoid

• Never perform simple incision and drainage of thrombosed external hemorrhoids, as this leads to persistent bleeding and higher recurrence rates 1, 3
• Never use corticosteroid creams for more than 7 days, as prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 3
• Never attribute all anorectal symptoms to hemorrhoids without proper evaluation, as other conditions like anal fissures, abscesses, or fistulas may coexist 3
• Never assume hemorrhoids are the cause of anemia or positive fecal occult blood until the colon is adequately evaluated with colonoscopy 3

Management of Thrombosed External Hemorrhoids with Constipation

If thrombosed external hemorrhoids develop:

• Within 72 hours of symptom onset: Complete surgical excision under local anesthesia provides faster pain relief and reduced risk of recurrence 1, 3
• Beyond 72 hours: Conservative management is preferred with topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks, as natural resolution has typically begun 1, 3

Continue aggressive constipation management throughout treatment to prevent recurrence 1.