What oral treatment regimen is recommended for adults with mild‑to‑moderate hemorrhoids?

Oral Treatment for Mild-to-Moderate Hemorrhoids

For adults with mild-to-moderate hemorrhoids, the recommended oral treatment regimen is micronized purified flavonoid fraction (MPFF) combined with increased dietary fiber (25-30 grams daily) and adequate water intake, as this combination addresses both acute symptoms and underlying pathophysiology. 1, 2

First-Line Oral Pharmacological Therapy

Flavonoids (Phlebotonics)

• Flavonoids are the primary oral medication recommended for hemorrhoidal symptom relief, working by improving venous tone and reducing bleeding, pain, and swelling across all hemorrhoid grades. 1, 2, 3

• Micronized purified flavonoid fraction (MPFF) is specifically recommended for controlling acute bleeding in patients awaiting definitive outpatient treatment. 3

• The major limitation is that symptom recurrence reaches 80% within 3-6 months after cessation, so flavonoids should be viewed as acute symptom control rather than curative therapy. 1, 4

• Despite high recurrence rates, flavonoids remain the only oral medication with moderate-quality evidence supporting their use for hemorrhoidal disease. 5

Dietary Fiber Supplementation

• Bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) are essential first-line therapy to regulate bowel movements and reduce straining. 1

• Dietary fiber intake should be increased to 25-30 grams daily through diet or supplementation. 1, 5

• Fiber supplementation works by producing soft, bulky stools that reduce mechanical trauma during defecation. 6

• This approach is recommended not only for acute treatment but also as long-term prophylaxis and in the perioperative period. 7

Adjunctive Oral Medications

Stool Softeners

• Osmotic laxatives such as polyethylene glycol or lactulose can be used safely, particularly in pregnant patients. 1

• Stool softeners are recommended for thrombosed external hemorrhoids presenting beyond 72 hours of onset. 4

Oral Analgesics

• Over-the-counter oral analgesics (acetaminophen or ibuprofen) provide additional pain control for symptomatic hemorrhoids. 1

• NSAIDs cannot be specifically recommended for complicated hemorrhoids based on available literature, as guideline societies note insufficient evidence. 5

Treatment Algorithm Based on Hemorrhoid Grade

Grade I-II Internal Hemorrhoids

• Start with flavonoids plus dietary fiber (25-30 g/day) and adequate hydration. 1, 2, 3

• Add stool softeners if constipation persists despite fiber supplementation. 1

• If symptoms persist after 1-2 weeks, consider office-based procedures like rubber band ligation. 1, 4

Grade III Internal Hemorrhoids

• Initiate the same oral regimen (flavonoids, fiber, hydration). 1, 2

• If conservative management fails, rubber band ligation achieves 89% success rates and should be the first procedural intervention. 1

• Excisional hemorrhoidectomy is reserved for failure of medical and office-based therapy. 1

External Hemorrhoids (Non-Thrombosed)

• Oral therapy alone is rarely sufficient; combine with topical treatments. 1, 2

• Flavonoids can provide symptomatic relief for bleeding and swelling. 2

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks achieves 92% resolution rates. 1, 5

Thrombosed External Hemorrhoids

• For presentation within 72 hours: surgical excision under local anesthesia provides fastest pain relief and lowest recurrence. 1, 4

• For presentation beyond 72 hours: conservative management with stool softeners, oral analgesics, and topical treatments is preferred as natural resolution has typically begun. 1, 4

Special Populations

Pregnant Patients

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly during the third trimester. 1

• Safe oral treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk. 1

• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely during pregnancy. 1

• Hydrocortisone foam can be used safely in the third trimester with no adverse events. 1

Critical Pitfalls to Avoid

• Never assume all rectal bleeding is from hemorrhoids—hemorrhoids alone do not cause positive stool guaiac tests, and fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated. 1, 5

• Do not rely on oral medications alone for definitive cure—drug treatment is aimed at controlling acute symptoms, not curing hemorrhoids. 3

• Avoid attributing anemia to hemorrhoids without proper evaluation, as anemia from hemorrhoidal disease is rare (0.5 patients per 100,000 population). 1

• Do not continue flavonoids indefinitely without reassessment, given the 80% symptom recurrence rate within 3-6 months after cessation. 1, 4

• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary. 1

When Oral Therapy Alone Is Insufficient

• Rubber band ligation should be considered for grade I-III internal hemorrhoids with persistent symptoms despite 1-2 weeks of conservative management, with success rates of 70.5-89%. 1, 8

• Excisional hemorrhoidectomy is the most effective treatment overall for grade III-IV hemorrhoids, with recurrence rates of only 2-10%, though recovery takes 9-14 days. 1, 4

• Office-based procedures (rubber band ligation, sclerotherapy, infrared coagulation) are preferred over surgery initially due to lower pain and complication rates. 1