What are the treatment options for a patient with hemorrhoids?

Hemorrhoid Treatment

Start all hemorrhoid patients with conservative management—increased dietary fiber (25-30 grams daily), adequate water intake, and avoidance of straining during defecation—regardless of hemorrhoid grade or severity. 1, 2, 3

Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications

• Increase fiber intake to 25-30 grams daily using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) or dietary sources to soften stool and reduce straining 1, 2, 3
• Increase water intake substantially to produce soft, bulky stools that pass without straining 1, 2
• Avoid straining during defecation completely—this is the single most important preventive measure 1, 2
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Topical Pharmacological Treatment

• For symptomatic relief, apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks—this achieves a 92% resolution rate compared to only 45.8% with lidocaine alone 1, 2, 3
• This combination works by relaxing internal anal sphincter hypertonicity (nifedipine) while providing local pain relief (lidocaine), with no systemic side effects 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, 3
• Topical nitrates show good results but are limited by high incidence of headache (up to 50% of patients) 1

Oral Pharmacological Treatment

• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling through improvement of venous tone, but have a major limitation: 80% symptom recurrence within 3-6 months after cessation 1, 4
• Over-the-counter oral analgesics (acetaminophen or ibuprofen) provide additional pain control 1

Important caveat: Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion—clinical data supporting their effectiveness are lacking 1

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

If conservative management fails after 1-2 weeks, proceed to office-based procedures for grade I-III internal hemorrhoids. 1

Rubber Band Ligation (First-Line Procedural Treatment)

• Rubber band ligation is the most effective office-based procedure with success rates of 70.5-89% depending on hemorrhoid grade 1, 2, 4
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerve afferents are absent above the anal transition zone 1, 2
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer to limit treatment to 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients) but is typically minor and manageable with sitz baths and over-the-counter analgesics 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) due to increased risk of necrotizing pelvic infection 1, 2

Alternative Office-Based Procedures

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage, with short-term efficacy in 70-85% of patients but long-term remission in only one-third 1, 4
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours of Symptom Onset)

For thrombosed external hemorrhoids presenting within 72 hours, perform complete surgical excision under local anesthesia—this provides faster pain relief and lower recurrence rates compared to conservative management 1, 2, 3, 4

Critical pitfall: Never perform simple incision and drainage of the thrombus—this leads to persistent bleeding and significantly higher recurrence rates 1, 2, 3

Late Presentation (>72 Hours After Onset)

For presentation beyond 72 hours, use conservative management as the natural resolution process has typically begun 1, 3, 4

• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1, 2
• Stool softeners and oral/topical analgesics (5% lidocaine) 1, 4
• Topical muscle relaxants for additional pain relief with severe sphincter spasm 1

Surgical Management

Indications for Hemorrhoidectomy

Proceed to surgical hemorrhoidectomy for:

• Failure of medical and office-based therapy 1, 3
• Symptomatic grade III-IV hemorrhoids 1, 3
• Mixed internal and external hemorrhoids 1, 3
• Anemia from hemorrhoidal bleeding 1
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 1

Surgical Technique

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with a low recurrence rate of 2-10% 1, 3, 4

• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning 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

Techniques to absolutely avoid:

• Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1, 3
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Alternative Surgical Approaches

• Stapled hemorrhoidopexy shows less postoperative pain and faster recovery but higher recurrence rates—lacks long-term follow-up data 1, 4
• Hemorrhoidal artery ligation (HAL/RAR) demonstrates better tolerance but higher recurrence rate 1

Critical Diagnostic Considerations

Do not attribute all anorectal symptoms to hemorrhoids without proper evaluation:

• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1, 3
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population)—always perform colonoscopy to rule out proximal colonic pathology 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), abscess, or thrombosis 1
• Perform anoscopy when feasible to assess for internal hemorrhoids and rule out other causes 1, 3
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 1, 3

Special Populations

Pregnancy

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

Immunocompromised Patients

Patients with uncontrolled diabetes, HIV/AIDS, neutropenia, or on immunosuppressive medications have increased risk of necrotizing pelvic infection and require closer monitoring—rubber band ligation is contraindicated in this population 1, 2