Management of Hemorrhoids in Adults
Begin with conservative management—increased dietary fiber (25-30 g/day), adequate hydration, and topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks—for all symptomatic hemorrhoids regardless of grade. 1
Initial Assessment
Perform anoscopy when tolerable to visualize hemorrhoid location (internal vs. external), grade internal hemorrhoids (I-IV), and exclude other anorectal pathology such as fissures, abscesses, or neoplasms. 1
Critical diagnostic pitfalls:
- Never attribute fecal occult blood or anemia to hemorrhoids without colonoscopy to exclude proximal colonic pathology. 1
- Anal pain suggests complications (thrombosis, fissure, abscess) rather than uncomplicated hemorrhoids, which typically cause painless bleeding. 1
- Anemia from hemorrhoids is rare (0.5/100,000 population); its presence warrants complete colonic evaluation. 1
Conservative Management (First-Line for All Grades)
Dietary and lifestyle modifications:
- Increase fiber intake to 25-30 g daily using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) or bulk-forming agents. 1
- Adequate water intake to produce soft, bulky stools and eliminate straining. 1
- Regular sitz baths (warm water soaks) reduce inflammation and discomfort. 1
Topical pharmacotherapy:
- Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks achieves 92% resolution versus 45.8% with lidocaine alone. 1 This is the most effective topical regimen, working by relaxing internal anal sphincter hypertonicity without systemic side effects. 1
- Lidocaine 1.5-2% ointment provides symptomatic relief of pain and itching. 1
- Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to prevent thinning of perianal and anal mucosa. 1
- Topical nitrates (nitroglycerin) show efficacy but are limited by high headache incidence (up to 50%). 1
Oral agents:
- Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation. 1
Management of Thrombosed External Hemorrhoids
Timing determines treatment:
Within 72 Hours of Symptom Onset
Complete surgical excision under local anesthesia is the treatment of choice, providing faster pain relief and lower recurrence rates compared to conservative management. 1, 2
Surgical technique:
- Excise the entire thrombosed hemorrhoid in one piece under local anesthesia as an outpatient procedure. 1
- Leave the wound open to heal by secondary intention. 1
- Never perform simple incision and drainage—this causes persistent bleeding and significantly higher recurrence rates. 1, 3, 2
Beyond 72 Hours of Symptom Onset
Conservative management is preferred, as natural resolution has typically begun. 1, 2
- Apply topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks. 1, 2
- Stool softeners, oral analgesics (NSAIDs, acetaminophen), and sitz baths. 1
- Short-term topical corticosteroids (≤7 days). 2
If Thrombosed Hemorrhoid Has Ruptured
Surgical excision is generally unnecessary, as natural drainage has occurred. 3
- Clean the area gently with warm water and mild soap. 3
- Apply direct pressure if active bleeding persists. 3
- Continue conservative management with topical nifedipine/lidocaine and dietary modifications. 3
- Reassess if symptoms fail to improve within 1-2 weeks. 3
Office-Based Procedures for Internal Hemorrhoids
Rubber band ligation is the most effective office-based procedure for persistent grade I-III internal hemorrhoids after conservative management fails, with success rates of 70.5-89%. 1
Technique:
- Place bands at least 2 cm proximal to the dentate line to avoid severe pain (somatic nerve afferents are absent above the anal transition zone). 1
- Treat 1-2 hemorrhoid columns per session (up to 3 maximum). 1
- Rubber band ligation is more effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation. 1
Complications:
- Pain (5-60% of patients), typically minor and manageable with sitz baths and over-the-counter analgesics. 1
- Severe bleeding when eschar sloughs (1-2 weeks post-treatment). 1
- Necrotizing pelvic sepsis is rare but serious—avoid in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes). 1
Alternative office procedures:
- Injection sclerotherapy is suitable for grade I-II hemorrhoids but less effective than rubber band ligation. 1
- Infrared photocoagulation has 67-96% success for grade I-II hemorrhoids but requires more repeat treatments. 1
- Bipolar diathermy achieves 88-100% bleeding control in grade II hemorrhoids. 1
Surgical Management
Indications for hemorrhoidectomy:
- Failure of conservative and office-based therapy. 1
- Symptomatic grade III-IV hemorrhoids. 1
- Mixed internal and external hemorrhoids. 1
- Anemia from hemorrhoidal bleeding. 1
- Concomitant anorectal conditions (fissure, fistula) requiring surgery. 1
Surgical options:
- Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with recurrence rates of only 2-10%. 1
- Ferguson (closed) technique may offer slightly improved wound healing compared to open technique. 1
- Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks. 1
Techniques to avoid:
- Anal dilatation should be abandoned—it causes 52% incontinence rate at 17-year follow-up. 1
- Cryotherapy causes prolonged pain, foul-smelling discharge, and requires more additional therapy. 1
Special Populations
Pregnancy:
- Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in the third trimester. 1
- Safe treatments include dietary fiber, adequate fluids, psyllium husk, and osmotic laxatives (polyethylene glycol, lactulose). 1
- Hydrocortisone foam can be used safely in the third trimester. 1
Patients on anticoagulation:
- Attempt conservative management first. 1
- If surgical excision is necessary within 72 hours, assess coagulation status and consider temporary anticoagulation adjustment in consultation with the prescribing physician. 1
Immunocompromised patients:
- Increased risk of necrotizing pelvic infection with rubber band ligation—avoid this procedure. 1
- Require closer monitoring for infection. 3