What is the recommended treatment for symptomatic hemorrhoids?

Treatment of Hemorrhoids

First-Line Conservative Management (Mandatory for All Grades)

All symptomatic hemorrhoids—regardless of grade—must begin with conservative therapy combining dietary modification, lifestyle changes, and pharmacological support. 1, 2

• Increase dietary fiber to 25–30 grams daily (approximately 5–6 teaspoons of psyllium husk mixed with 600 mL water) to soften stool and reduce straining 1, 3
• Ensure adequate daily water intake to maintain soft, bulky stools and minimize anorectal pressure during defecation 1, 2
• Avoid prolonged sitting on the toilet to prevent elevation of venous pressure in the hemorrhoidal plexus 1
• Perform warm-water sitz baths to reduce perianal inflammation and provide symptomatic relief 1

Pharmacological Adjuncts to Conservative Therapy

Flavonoids (phlebotonics such as diosmin/hesperidin) should be combined with fiber and hydration as first-line pharmacological therapy for all grades of symptomatic hemorrhoids. 1, 3

• Diosmin reduces bleeding, pain, swelling, pruritus, and discharge with statistically significant improvements demonstrated in a Cochrane meta-analysis of 24 randomized trials (2,334 participants) 1, 3
• Symptom recurrence reaches 80% within 3–6 months after cessation, requiring ongoing dietary measures and consideration of definitive treatment for persistent disease 1, 4
• Flavonoids must never be prescribed as monotherapy; they are ineffective without concurrent fiber, hydration, and lifestyle modifications 3

Topical Treatments for Symptom Relief

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution for thrombosed external hemorrhoids compared to 45.8% with lidocaine alone 1
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 3, 2
• Topical nitrates (e.g., nitroglycerin) show efficacy but are limited by high incidence of headache (up to 50% of patients), making nifedipine the preferred topical muscle relaxant 1

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Office-Based Procedures for Persistent Grade I–III Internal Hemorrhoids

When conservative management fails after 4–8 weeks, rubber band ligation is the first-line office-based procedure for grade I–III internal hemorrhoids. 1, 4

Rubber Band Ligation (Preferred Office Procedure)

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and length of follow-up 1
• More effective than sclerotherapy and requires fewer repeat treatments than sclerotherapy or infrared photocoagulation 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerve afferents are absent above the anal transition zone 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer to limit treatment to 1–2 columns at a time 1
• Pain is the most common complication (5–60% of patients), typically minor and manageable with sitz baths and over-the-counter analgesics 1
• Necrotizing pelvic sepsis is rare but serious, with increased risk in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) 1

Alternative Office-Based Procedures

• Sclerotherapy is suitable for first- and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage, with 70–85% short-term efficacy but only one-third achieving long-term remission 1, 4
• Infrared photocoagulation has 67–96% success rates for grade I–II hemorrhoids but requires more repeat treatments 1
• Bipolar diathermy achieves 88–100% success for bleeding control in grade II hemorrhoids 1

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Surgical Management for Grade III–IV Hemorrhoids or Failed Conservative/Office Therapy

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III–IV hemorrhoids, mixed internal and external hemorrhoids, and when concomitant anorectal conditions require surgery. 1, 4

Conventional Excisional Hemorrhoidectomy (Gold Standard)

• Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) is the most effective treatment overall, particularly for grade III–IV hemorrhoids, with recurrence rates of only 2–10% 1, 4
• Ferguson (closed) technique involves excising hemorrhoid components and closing wounds primarily, associated with reduced postoperative pain and 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
• Complications include urinary retention (2–36%), bleeding (0.03–6%), anal stenosis (0–6%), infection (0.5–5.5%), and incontinence (2–12%) 1

Alternative Surgical Approaches

• Stapled hemorrhoidopexy shows less postoperative pain, shorter operation time, and faster recovery but has higher recurrence rates compared to excisional hemorrhoidectomy 1, 5
• Hemorrhoidal artery ligation (HAL) with or without recto-anal repair (RAR) demonstrates better tolerance but higher recurrence rates compared to conventional hemorrhoidectomy 1, 5

Procedures to Avoid

• Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

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Management of Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours of symptom onset, complete excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management. 1, 4

Early Presentation (≤72 Hours)

• Complete surgical excision under local anesthesia is the treatment of choice, performed as an outpatient procedure with low complication rates 1
• Simple incision and drainage is contraindicated because it leads to persistent bleeding and significantly higher recurrence rates; complete excision is mandatory 1, 2
• The entire thrombosed hemorrhoid should be excised in one piece, with the wound left open to heal by secondary intention 1

Late Presentation (>72 Hours)

• Conservative management is preferred when natural resolution has typically begun, as the benefit of surgical excision diminishes after 72 hours 1, 4
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks achieves 92% resolution 1
• Stool softeners, oral analgesics (NSAIDs or acetaminophen), sitz baths, and topical lidocaine provide comfort and promote healing 1

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Critical Diagnostic Considerations and Red Flags

Hemorrhoids alone do not cause positive stool guaiac tests or significant anemia; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated. 1

• Anemia due to hemorrhoidal disease is rare (approximately 0.5 patients per 100,000 population) 1
• Colonoscopy is mandatory when bleeding is atypical, anemia is present, or the patient has significant risk factors for colonic neoplasia 1, 3
• Anal pain is generally not associated with uncomplicated internal hemorrhoids; its presence suggests other pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids), abscess, or thrombosis 1
• Anoscopy should be performed when feasible and well tolerated to rule out other causes of anorectal symptoms 1, 2

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Special Populations and Considerations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents (psyllium husk), and osmotic laxatives (polyethylene glycol or lactulose) 1
• Hydrocortisone foam can be used safely in the third trimester with no adverse events compared to placebo 1

Patients with Hemorrhoidal Bleeding and Anemia

• Hemorrhoidectomy is indicated for patients with anemia from hemorrhoidal bleeding, as it represents a critical threshold demanding definitive surgical intervention 1
• Blood transfusion may be needed given low hemoglobin levels, and preoperative optimization should be considered if hemodynamically stable 1
• Colonoscopy must be performed to rule out proximal colonic pathology before attributing anemia solely to hemorrhoids 1, 3

Immunocompromised Patients

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) have increased risk of necrotizing pelvic infection from rubber band ligation and should avoid office-based procedures 1

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Common Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to exclude inflammatory bowel disease, colorectal cancer, or other proximal colonic pathology 1, 3
• Never use topical corticosteroids for more than 7 days, as prolonged use causes thinning of perianal and anal mucosa and increases injury risk 1, 3, 2
• Never perform simple incision and drainage of thrombosed external hemorrhoids; complete excision is required if surgical intervention is chosen 1, 2
• Never prescribe flavonoids as monotherapy; they must be paired with fiber, adequate hydration, and lifestyle measures to achieve therapeutic benefit 3
• Do not delay surgical excision of thrombosed external hemorrhoids beyond 72 hours if the patient presents early, as the benefit of intervention declines after this period 1