How should an inflamed hemorrhoid be managed?

Treatment of Inflamed Hemorrhoids

For inflamed hemorrhoids, begin immediately with conservative management including increased fiber (25-30g daily) and water intake, combined with flavonoids for symptom relief, and add topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks if thrombosed or severely symptomatic. 1, 2, 3

First-Line Conservative Management (All Grades)

Dietary and lifestyle modifications are the foundation of treatment and should be initiated for all patients regardless of hemorrhoid severity. 1, 3

• Increase dietary fiber to 25-30 grams daily through diet or supplementation with psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1, 3
• Ensure adequate water intake to complement fiber supplementation and prevent constipation 1, 3
• Avoid straining during defecation as this is the primary exacerbating factor 2, 3
• Sitz baths provide symptomatic relief and should be recommended alongside other measures 2, 3

Pharmacological Treatment Algorithm

For All Inflamed Hemorrhoids (Internal or External)

Flavonoids (phlebotonics) are recommended as first-line pharmacological therapy to improve venous tone and relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2, 3

For Thrombosed or Severely Painful Hemorrhoids

Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to only 45.8% with lidocaine alone, with no systemic side effects 2, 3, 4

• This combination works by relaxing internal anal sphincter hypertonicity which contributes to pain 2, 3
• Topical muscle relaxants are specifically suggested for thrombosed or strangulated hemorrhoids to provide relief from anal sphincter spasm 1, 2

Adjunctive Topical Therapies

• Topical lidocaine (1.5-2%) provides symptomatic relief of local pain and itching, though data supporting long-term efficacy are limited 2, 3
• Topical corticosteroid creams may ameliorate local perianal inflammation BUT MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2, 3, 4
• Topical nitrates have shown good results for thrombosed external hemorrhoids but high incidence of headache (up to 50%) may limit their use 2, 3
• Topical heparin has been found to significantly improve healing and resolution, although evidence is limited to small studies 2, 3

Critical Timing Considerations for Thrombosed External Hemorrhoids

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 2, 3

• Beyond 72 hours, conservative management is preferred as natural resolution has typically begun 2, 3
• Never perform simple incision and drainage of the thrombus alone, as this leads to persistent bleeding and higher recurrence rates 2, 3, 4

When to Escalate Treatment

If symptoms persist or worsen despite 1-2 weeks of conservative and pharmacological management, consider procedural interventions:

• Rubber band ligation is the preferred office-based procedure for persistent grade I-III internal hemorrhoids, with success rates of 70.5-89% 2, 3
• Surgical hemorrhoidectomy is indicated for failure of medical and non-operative therapy, symptomatic grade III-IV hemorrhoids, or mixed internal and external hemorrhoids 2, 3

Critical Pitfalls to Avoid

• Never use topical corticosteroids for more than 7 days as prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury 1, 2, 3, 4
• Do not blindly attribute rectal bleeding to hemorrhoids without proper evaluation, as it may indicate inflammatory bowel disease, colorectal cancer, or other serious conditions 1, 3, 4
• Anoscopy should be performed when feasible and well tolerated to confirm diagnosis, though patients with thrombosed hemorrhoids may experience excruciating pain requiring sedation 1, 3
• Consider colonoscopy if there is concern for inflammatory bowel disease or cancer based on patient personal and family history, or atypical bleeding patterns 1, 3, 4

Special Populations

For pregnant patients with hemorrhoids:

• Dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk are safe 3
• Osmotic laxatives such as polyethylene glycol or lactulose can be used safely 3
• Hydrocortisone foam can be used safely in the third trimester 3