What are the treatment options for a patient presenting with hemorrhoids?

Treatment of Hemorrhoids

First-Line Conservative Management for All Grades

All hemorrhoid patients should begin with dietary and lifestyle modifications, including increased fiber intake to 25-30 grams daily (achievable with 5-6 teaspoonfuls of psyllium husk with 600 mL water), adequate water intake to soften stool, and complete avoidance of straining during defecation. 1, 2

• Bulk-forming agents like psyllium husk are recommended to regulate bowel movements and prevent recurrence 1
• Stool softeners should be used to reduce straining 1
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1
• Conservative management alone successfully treats over 90% of symptomatic hemorrhoids when combined with office procedures 3

Topical Pharmacological Treatment

For symptomatic relief, topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks is the most effective medical treatment, achieving 92% resolution compared to only 45.8% with lidocaine alone. 1, 2

• This combination works by relaxing internal anal sphincter hypertonicity and providing local anesthetic effect 1
• No systemic side effects have been observed with topical nifedipine 1
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 1
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 4

Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails, with success rates of 70.5-89%. 1, 2

• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1, 2
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners limit treatment to 1-2 columns 1
• Rubber band ligation is more effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• Pain is the most common complication (5-60% of patients) but is typically manageable with sitz baths and over-the-counter analgesics 1
• Repeated banding is needed in up to 20% of patients 4

Alternative Office Procedures

• Sclerotherapy is suitable for first and second-degree hemorrhoids, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 4
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1
• Bipolar diathermy achieves 88-100% success for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and when concomitant anorectal conditions require surgery. 1

• Hemorrhoidectomy is the most effective treatment overall with recurrence rates of only 2-10% 1, 4
• Anemia from hemorrhoidal bleeding is an absolute indication for hemorrhoidectomy 1, 5
• Grade IV hemorrhoids always require surgical evaluation 5

Surgical Technique Selection

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) remains the gold standard for grade III-IV hemorrhoids, with the Ferguson technique offering slightly improved wound healing. 1, 6

• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Postoperative urinary complications occur in 20% of patients 3
• Delayed hemorrhage occurs in 2.4% of patients 3

Alternative Surgical Options

• Stapled hemorrhoidopexy shows faster postoperative recovery and less pain but has higher recurrence rates and risk of serious complications including rectal perforation and pelvic sepsis 1, 6, 7
• Hemorrhoidal artery ligation (HAL/RAR) demonstrates better tolerance but higher recurrence rates 6

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management. 1, 2, 4

• Excision can be performed as an outpatient procedure with low complication rates 1
• Never perform simple incision and drainage as this leads to persistent bleeding and significantly higher recurrence rates 1, 2

Late Presentation (Beyond 72 Hours)

For presentation 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 1
• Use stool softeners and oral analgesics 4
• Topical corticosteroids for ≤7 days may reduce inflammation 1

Procedures to Avoid

Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up and sphincter injuries. 1

• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Suppository medications lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

When to Refer for Specialist Evaluation

Immediate referral is indicated for anemia from hemorrhoidal bleeding, severe bleeding with hemodynamic instability, fever with severe pain suggesting necrotizing pelvic sepsis, or symptoms persisting beyond 1-2 weeks despite appropriate conservative treatment. 5

• Grade III hemorrhoids with persistent bleeding or prolapse after office procedures require referral 5
• Grade IV hemorrhoids always require surgical referral 5
• Fecal occult blood positivity requires colonoscopy as hemorrhoids alone do not cause positive stool guaiac tests 1, 5
• Significant anal pain suggests alternative pathology such as anal fissure or abscess, not uncomplicated hemorrhoids 1, 5

Critical Pitfalls to Avoid

• Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1, 5
• Never use corticosteroid creams for more than 7 days due to risk of perianal tissue thinning 1, 2
• Never assume all anorectal symptoms are hemorrhoids, as other conditions are frequently misattributed 1, 5
• Immunocompromised patients (uncontrolled diabetes, HIV/AIDS, neutropenia) have increased risk of necrotizing pelvic infection and require closer monitoring 1, 2