What is the recommended treatment for a patient with active hemorrhoids?

Treatment for Active Hemorrhoids

Begin with conservative management for all hemorrhoid grades, including increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining during defecation, as this is first-line therapy regardless of hemorrhoid severity. 1, 2

Initial Conservative Management (First-Line for All Grades)

Dietary and lifestyle modifications form the foundation of hemorrhoid treatment:

• Increase fiber intake to 25-30 grams daily, achievable with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL water daily 1, 2
• Ensure adequate water intake to soften stool and reduce straining 1, 2
• Avoid prolonged straining during defecation 1, 2
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological options for symptom relief:

• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling through improved venous tone, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate (compared to 45.8% with lidocaine alone) for thrombosed hemorrhoids, with no systemic side effects 1, 2, 4
• Short-term topical corticosteroids (≤7 days maximum) may reduce local perianal inflammation, but must never exceed 7 days to avoid thinning of perianal and anal mucosa 1, 2, 4
• Topical lidocaine (1.5-2% ointment) provides symptomatic relief of local pain and itching 1, 4

Office-Based Procedures (When Conservative Management Fails)

For persistent grade I-III internal hemorrhoids after failed conservative therapy:

Rubber band ligation is the preferred first-line procedural intervention, with success rates of 70.5-89% depending on hemorrhoid grade, and superior efficacy compared to sclerotherapy or infrared photocoagulation 1, 2, 3

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

Alternative office-based procedures (less effective than rubber band ligation):

• Sclerotherapy is suitable for first and second-degree hemorrhoids, with 70-85% short-term efficacy but only one-third achieving long-term remission 1, 3
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1, 3
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Management of Thrombosed External Hemorrhoids

Timing determines treatment approach:

Within 72 hours of symptom onset:

• Surgical excision under local anesthesia is preferred, providing faster pain relief and lower recurrence rates compared to conservative management 1, 2, 4, 3
• Complete excision is required; simple incision and drainage is NOT recommended due to persistent bleeding and higher recurrence rates 1, 2, 4

Beyond 72 hours of symptom onset:

• Conservative management is preferred as natural resolution has typically begun 1, 2, 4, 3
• Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1, 2, 4
• Use stool softeners, oral and topical analgesics such as 5% lidocaine 1, 3
• Flavonoids can relieve symptoms 4

Surgical Management (For Advanced Disease or Failed Conservative/Office-Based Therapy)

Indications for hemorrhoidectomy:

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

Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for third-degree hemorrhoids, with low recurrence rates of 2-10% 1, 2, 3

• Ferguson (closed) technique may offer slightly improved wound healing compared to Milligan-Morgan (open) technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Alternative surgical options:

• Stapled hemorrhoidopexy shows less postoperative pain and faster recovery but higher recurrence rates 1
• Hemorrhoidal artery ligation (HAL/RAR) demonstrates better tolerance but higher recurrence rates 1

Critical Pitfalls to Avoid

Never attribute bleeding or anemia to hemorrhoids without proper evaluation:

• Hemorrhoids alone do not cause positive stool guaiac tests 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients per 100,000 population) 1
• Colonoscopy should be performed if there is concern for inflammatory bowel disease or cancer, or if bleeding is atypical 1, 2, 4

Avoid these obsolete or harmful procedures:

• Anal dilatation causes 52% incontinence rate at 17-year follow-up 1
• Cryotherapy causes prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Simple incision and drainage of thrombosed hemorrhoids leads to persistent bleeding and higher recurrence 1, 2, 4

Medication precautions:

• Never use corticosteroid creams for more than 7 days due to risk of perianal tissue thinning 1, 2, 4
• Suppository medications lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1
• Long-term use of high-potency corticosteroid suppositories is potentially harmful 1, 4

Special Considerations

Anal pain suggests alternative pathology:

• Uncomplicated hemorrhoids generally do not cause anal pain 1
• Pain presence suggests anal fissure (occurs in up to 20% of patients with hemorrhoids), abscess, or thrombosis 1

Immunocompromised patients:

• Have increased risk of necrotizing pelvic infection with rubber band ligation 1
• Includes patients with uncontrolled AIDS, neutropenia, and severe diabetes mellitus 1

Pregnancy considerations:

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, osmotic laxatives (polyethylene glycol or lactulose), and hydrocortisone foam in third trimester 1