What are the treatment options for a patient with hemorrhoids?

Hemorrhoid Treatment

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

Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications:

• Increase fiber intake to 25-30 grams per day using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1, 2
• Ensure adequate hydration to prevent constipation 1
• Avoid prolonged straining during bowel movements 1
• Take warm sitz baths to reduce inflammation and discomfort 1

Pharmacological Treatment:

• For thrombosed or symptomatic hemorrhoids: Apply topical nifedipine 0.3% with lidocaine 1.5% every 12 hours for two weeks—this achieves 92% resolution compared to 45.8% with lidocaine alone 1, 2
• Phlebotonics (flavonoids/diosmin): Relieve bleeding, pain, and swelling through improved venous tone, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 3, 4
• Topical corticosteroids: May reduce local inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2

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

When conservative management fails after adequate trial:

• Rubber band ligation is first-line procedural treatment with success rates of 70.5-89% depending on grade, more effective than sclerotherapy and requiring fewer repeat treatments 1, 2, 4
• Place bands at least 2 cm proximal to the dentate line to avoid severe pain 2
• Can treat up to 3 hemorrhoids per session, though many limit to 1-2 columns 2

Alternative office procedures:

• Sclerotherapy: Suitable for grade I-II hemorrhoids with 70-85% short-term success but only one-third achieve long-term remission 2, 4
• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids but requires more repeat treatments 2, 4

Management of Thrombosed External Hemorrhoids

Timing determines treatment approach:

Within 72 hours of symptom onset:

• Complete surgical excision under local anesthesia provides faster pain relief and reduced recurrence risk compared to conservative management 1, 2, 4
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates 1, 2

Beyond 72 hours:

• Conservative management is preferred as natural resolution has begun 1, 2
• Use topical nifedipine 0.3% with lidocaine 1.5% every 12 hours for two weeks (92% resolution rate) 1, 2
• Stool softeners and oral/topical analgesics (5% lidocaine) 4

Surgical Management (Grade III-IV or Failed Conservative/Office Therapy)

Indications for hemorrhoidectomy:

• Failure of medical and office-based therapy 2
• Symptomatic grade III-IV hemorrhoids 1, 2
• Mixed internal and external hemorrhoids 2
• Anemia from hemorrhoidal bleeding 2
• Concomitant anorectal conditions requiring surgery 2

Surgical approach:

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is most effective with 2-10% recurrence rate 1, 2, 4
• Ferguson closed technique may offer slightly improved wound healing and reduced postoperative pain 2
• Expect 2-4 weeks recovery time with narcotic analgesics required 2

Critical Assessment Before Treatment

Before attributing bleeding to hemorrhoids:

• Check vital signs, hemoglobin, and hematocrit to assess bleeding severity 1, 5
• Perform anoscopy when feasible to visualize hemorrhoids 1, 5
• Patients over 50 years or with risk factors for colorectal cancer require colonoscopy before treating hemorrhoids to rule out malignancy 1, 2
• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood requires colonic evaluation 2
• Anemia from hemorrhoids is rare (0.5 per 100,000 population) 2

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days—prolonged use causes perianal and anal mucosa thinning 1, 2, 5
• Never perform simple incision and drainage of thrombosed hemorrhoids—complete excision is required if surgical intervention is chosen 1, 2
• Never attribute anemia or chronic bleeding to hemorrhoids without colonoscopy, especially in patients over 50 years 1, 2
• Never perform anal dilatation—causes sphincter injuries with 52% incontinence rate at 17-year follow-up 2
• Avoid cryotherapy due to prolonged pain, foul-smelling discharge, and need for additional therapy 2

Special Populations

Pregnancy:

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in third trimester 2
• Safe treatments include dietary fiber, adequate fluids, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol or lactulose) 2
• Hydrocortisone foam can be used safely in third trimester 2