What is the best treatment approach for a pregnant individual with hemorrhoids?

Treatment of Hemorrhoids in Pregnancy

Start with dietary fiber (30g/day) and adequate hydration, add psyllium husk or polyethylene glycol if constipation persists after 1 week, and use topical hydrocortisone for symptomatic relief—this conservative approach is safe and effective for the vast majority of pregnant patients with hemorrhoids. 1, 2

First-Line Conservative Management

Dietary and Lifestyle Modifications

• Increase dietary fiber to approximately 30g/day through fruits (3-4 servings daily), vegetables (3-4 servings daily), whole grains, and legumes to promote regular bowel movements and prevent constipation that worsens hemorrhoid symptoms 1, 2
• Ensure adequate fluid intake, particularly water, to soften stools and ease bowel movements 1, 2
• Avoid straining during bowel movements by allowing ample time, using relaxation techniques, and optimizing diet and hydration 1, 2
• Sitz baths provide symptomatic relief and are safe during pregnancy 2

Pharmacological Management for Constipation

If dietary modifications fail after 1 week, escalate to bulk-forming agents:

• Psyllium husk (Metamucil) or methylcellulose are first-line pharmacological options because they lack systemic absorption and are safe during pregnancy 1, 2
• Soluble fiber like psyllium improves stool viscosity and transit time in addition to increasing bulk 1

For persistent constipation:

• Polyethylene glycol (PEG) 17g daily can be safely administered during pregnancy 2, 1
• Lactulose is another safe osmotic laxative option 1, 3
• Magnesium hydroxide 400-500mg daily is safe and effective if needed 2
• Avoid stimulant laxatives because safety data during pregnancy are conflicting 1

Topical Symptomatic Relief

• Topical hydrocortisone cream or foam reduces perianal irritation, itching, and inflammation associated with hemorrhoids 1, 2, 3
• Hydrocortisone foam has been shown safe in the third trimester with no adverse events in a prospective study of 204 patients 1
• Limit topical corticosteroids to short-term use (≤7 days) to avoid thinning of perianal and anal mucosa 1, 3

Management of Thrombosed External Hemorrhoids

Timing determines the approach:

• For thrombosed hemorrhoids presenting within 72 hours of symptom onset: surgical excision under local anesthesia provides faster symptom resolution and lower recurrence rates 1
• For presentations beyond 72 hours: conservative management is preferred with stool softeners and topical analgesics 1

Surgical Intervention (Rare)

Approximately 0.2% of pregnant women require urgent hemorrhoidectomy for specific indications 1:

• Fourth-degree hemorrhoids (cannot be reduced, incarcerated, thrombosed) require surgical intervention 1
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids should undergo either hemorrhoidectomy or excision of the external component with rubber band ligation of internal hemorrhoids when conservative management fails 1
• Third-degree hemorrhoids (require manual reduction) should receive a trial of conservative management first, with surgery only if this fails 1

Critical Pitfalls to Avoid

• Do not assume all anorectal symptoms are due to hemorrhoids—other conditions like anal fissures may coexist in up to 20% of patients and require different management 1, 2, 3
• Avoid manual anal dilation due to the associated risk of sphincter injury and incontinence 1, 3
• Do not perform incision and drainage of thrombosed external hemorrhoids alone—this is ineffective in preventing recurrence 1, 3
• Avoid prolonged use of potent corticosteroid preparations as they may cause tissue thinning 1, 3

When to Seek Urgent Care

Patients should return immediately for:

• Massive or uncontrolled bleeding 3
• Severe pain not controlled with prescribed analgesics 3
• Prolapsed hemorrhoids that cannot be reduced 3
• Signs of infection or sepsis (fever, chills, purulent discharge) 3

Evidence Quality Note

The conservative approach represents a strong recommendation based on moderate-quality evidence and should be maintained throughout pregnancy 1. Most symptoms resolve spontaneously soon after delivery, making aggressive intervention during pregnancy rarely necessary 4, 5.