How should I manage an adult patient presenting with painful hemorrhoids?

Management of Painful Hemorrhoids

Start with conservative management including increased fiber (25-30g daily), adequate water intake, and topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks, which achieves 92% resolution for thrombosed external hemorrhoids. 1, 2

Immediate Assessment

Determine the specific cause of pain through focused examination:

• Thrombosed external hemorrhoid: Presents as a dome-shaped, bluish, tender perianal swelling below the dentate line with acute-onset pain 2
• Prolapsed/incarcerated internal hemorrhoid: Visible prolapsed tissue that cannot be reduced, often with severe pain 3
• Anal fissure: Sharp pain during and after defecation, often with visible tear on examination 4, 2
• Perianal abscess: Fluctuant mass with fever, severe pain, and systemic signs 5

Critical pitfall: Uncomplicated internal hemorrhoids do not cause pain—if pain is present, look for thrombosis, fissure, or abscess. 4, 2

Perform anoscopy when tolerable to visualize internal hemorrhoids and exclude other pathology, though this may require sedation in acute thrombosis. 1

First-Line Conservative Management (All Types)

Dietary and Lifestyle Modifications

• Increase fiber intake to 25-30 grams daily using psyllium husk (5-6 teaspoonfuls with 600 mL water daily) 1, 2
• Adequate water intake to soften stool and reduce straining 1, 2
• Avoid prolonged sitting on toilet and straining during defecation 2
• Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 2

Pharmacological Management

For thrombosed external hemorrhoids (most common cause of severe pain):

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution versus 45.8% with lidocaine alone 1, 2
• Nifedipine relaxes internal anal sphincter hypertonicity without systemic side effects 2
• Lidocaine provides immediate symptomatic pain relief 2

Alternative topical agents:

• Topical corticosteroids may reduce local inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2
• Topical nitrates show good results but are limited by high incidence of headache (up to 50%) 2
• Topical heparin significantly improves healing, though evidence is limited 2

Oral medications:

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 2
• Oral analgesics (acetaminophen or ibuprofen) for additional pain control 2
• Stool softeners to prevent straining 2

Surgical Management for Thrombosed External Hemorrhoids

Timing-Based Algorithm

If 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, 2
• Can be performed as outpatient procedure with low complication rates 2
• The wound is left open to heal by secondary intention 2

If presenting >72 hours after onset:

• Conservative management is preferred as natural resolution has typically begun 1, 2
• Continue topical nifedipine/lidocaine and supportive measures 2

Critical contraindication: Never perform simple incision and drainage of the thrombus—this leads to persistent bleeding and significantly higher recurrence rates. Complete excision is required if surgical intervention is chosen. 1, 2

Office-Based Procedures for Internal Hemorrhoids

If pain is from prolapsed internal hemorrhoids (not thrombosed external):

• Rubber band ligation is most effective for grades I-III internal hemorrhoids with 70.5-89% success rates 2, 6
• Must be placed ≥2 cm proximal to dentate line to avoid severe pain 2
• Contraindicated for acutely thrombosed or external hemorrhoids 2

Surgical Hemorrhoidectomy Indications

Consider for:

• Grade III-IV internal hemorrhoids with persistent symptoms 2, 6
• Mixed internal and external hemorrhoids 2
• Failure of conservative and office-based therapy 2
• Incarcerated/gangrenous prolapsed hemorrhoids requiring emergency intervention 3

Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan) has 2-10% recurrence rate but requires 2-4 weeks recovery. 2, 6

Red Flags Requiring Immediate Evaluation

• Fever >38.5°C, tachycardia, or hypotension suggests necrotizing pelvic sepsis—requires immediate broad-spectrum antibiotics and surgical consultation 5
• Severe bleeding with hemodynamic instability requires vital signs monitoring, CBC, coagulation studies, and blood type/crossmatch 4, 2
• Urinary retention with severe pain may indicate complication requiring emergency evaluation 2

When to Perform Colonoscopy

• All patients with rectal bleeding require at minimum sigmoidoscopy to exclude other sources 1, 4
• Complete colonoscopy indicated when bleeding is atypical for hemorrhoids, guaiac-positive stools present, anemia present, or colorectal cancer risk factors exist 1, 4
• Never attribute anemia to hemorrhoids without proper colonic evaluation—anemia from hemorrhoids is rare (0.5 per 100,000 population) 4, 2

Critical Pitfalls to Avoid

• Never use corticosteroid creams >7 days—causes perianal tissue thinning 1, 2
• Never perform anal dilatation—causes 52% incontinence rate at long-term follow-up 2
• Never attribute all anorectal symptoms to hemorrhoids without proper examination—up to 20% have concomitant anal fissure 4, 2
• Antibiotics are NOT indicated for uncomplicated hemorrhoids—only prescribe if abscess or systemic infection present 5