What medications and treatments can I prescribe for uncomplicated hemorrhoids in a non‑pregnant patient not on anticoagulants and without drug allergies?

What You Can Order for Hemorrhoids

Start with dietary fiber (25–30 g/day, such as 5–6 teaspoons psyllium husk mixed with 600 mL water), adequate hydration, and flavonoids (diosmin 450 mg/hesperidin 50 mg), combined with topical 0.3% nifedipine + 1.5% lidocaine ointment every 12 hours for symptomatic relief. 1, 2, 3

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First-Line Conservative Management (Mandatory for All Grades)

Dietary & Lifestyle Modifications:

• Prescribe fiber supplementation: 25–30 g daily, achievable with 5–6 teaspoons of psyllium husk mixed with 600 mL water 1, 3
• Instruct adequate daily water intake to soften stool and minimize straining during defecation 1, 3
• Advise avoiding prolonged sitting on the toilet to prevent elevation of venous pressure in the hemorrhoidal plexus 1
• Recommend warm-water sitz baths to lessen perianal inflammation and provide symptomatic relief 1, 3

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Pharmacologic Therapy

Flavonoids (Phlebotonics) – First-Line Pharmacologic Agent

• Prescribe diosmin 450 mg/hesperidin 50 mg (micronized purified flavonoid fraction) to relieve bleeding, pruritus, discharge, and overall symptoms 2, 4, 5
• Evidence base: A Cochrane meta-analysis of 24 RCTs (2,334 participants) demonstrated statistically significant improvements in pruritus, bleeding, post-hemorrhoidectomy bleeding, discharge, leakage, and overall symptom scores 2
• Critical limitation: Symptom recurrence reaches 80% within 3–6 months after cessation, so flavonoids must be combined with dietary measures and cannot be used as monotherapy 2, 5
• Dosing from FDA label: Multiple studies show resolution time of acute flares shortened from 8 days to 4–5 days with diosmin 4

Topical Treatments for Symptomatic Relief

Topical Nifedipine + Lidocaine (Most Effective Topical Agent):

• Prescribe 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks 1, 3
• Efficacy: 92% resolution rate compared to 45.8% with lidocaine alone 1, 3
• Mechanism: Nifedipine relaxes internal anal sphincter hypertonicity (calcium-channel blocker), while lidocaine provides immediate pain relief 1, 3
• Safety: No systemic side effects observed with topical nifedipine application 1, 3

Topical Corticosteroids (Short-Term Only):

• Prescribe hydrocortisone cream/suppository for perianal inflammation, but limit to ≤7 days maximum 1, 2, 3
• Critical warning: Long-term use causes thinning of perianal and anal mucosa, increasing injury risk 1, 2, 3

Topical Lidocaine (Standalone):

• Prescribe 2% lidocaine gel or 5% lidocaine patches for symptomatic relief of local pain and itching 1, 3
• Application: Can be applied up to 12–24 hours for gradual pain relief 3

Alternative Topical Agents (Less Preferred):

• Topical nitrates (nitroglycerin ointment): Show good results for pain relief but limited by high incidence of headache (up to 50% of patients) 1, 3
• Topical heparin: Significantly improves healing of acute hemorrhoids, though evidence is limited to small studies 1, 3

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Office-Based Procedures (When Conservative Management Fails After 1–2 Weeks)

Rubber Band Ligation (First-Line Procedural Intervention):

• Indicated for persistent grade I–III internal hemorrhoids after conservative management fails 3, 6, 7
• Success rates: 70.5–89% depending on hemorrhoid grade 1, 3, 6
• Technique: Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 3
• Advantage: More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1, 3, 7
• Limitation: Repeated banding needed in up to 20% of patients 5

Infrared Photocoagulation:

• Indicated for grade I–II hemorrhoids with bleeding as the primary symptom 3, 7
• Success rates: 67–96% for first or second-degree hemorrhoids 3
• Limitation: Requires more repeat treatments compared to rubber band ligation 3, 7

Sclerotherapy:

• Indicated for first and second-degree hemorrhoids 1, 3
• Efficacy: 70–85% short-term success, but long-term remission occurs in only one-third of patients 5
• Technique: Uses sclerosing agents to cause fibrosis and tissue shrinkage 1, 3

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Surgical Management (Reserved for Refractory or Higher-Grade Disease)

Indications for Hemorrhoidectomy:

• Failure of medical and office-based therapy 1, 3
• Symptomatic grade III or IV hemorrhoids 1, 3, 5
• Mixed internal and external hemorrhoids 1, 3
• Anemia from hemorrhoidal bleeding 3
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 3

Conventional Excisional Hemorrhoidectomy:

• Gold standard for grade IV hemorrhoids with recurrence rate of only 2–10% 1, 3, 7
• Techniques: Open (Milligan-Morgan) or closed (Ferguson) with no significant difference in outcomes 1, 3
• Drawback: Postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2–4 weeks 3

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Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours):

• Perform complete excision under local anesthesia as an outpatient procedure 1, 3, 5
• Benefit: Provides faster pain relief and reduced risk of recurrence compared to conservative management 1, 3, 5
• Critical warning: Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence rates; complete excision is required 1, 2, 3

Late Presentation (>72 Hours):

• Conservative management is preferred as natural resolution has typically begun 1, 3, 5
• Treatment: Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks, stool softeners, oral analgesics (NSAIDs or acetaminophen), sitz baths 1, 3, 5

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Critical Pitfalls to Avoid

• Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology (inflammatory bowel disease, colorectal cancer); anemia from hemorrhoids alone is rare (0.5 patients/100,000 population) 2, 3
• Never use topical corticosteroids beyond 7 days due to risk of perianal tissue thinning 1, 2, 3
• Never prescribe flavonoids as monotherapy—they must be paired with fiber, hydration, and lifestyle measures 2
• Never perform anal dilatation—52% incontinence rate at 17-year follow-up 1, 3
• Never perform cryotherapy—causes prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 3
• Avoid assuming all anorectal symptoms are hemorrhoids—anal fissures coexist in up to 20% of patients 3

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When to Reassess or Refer

• If symptoms worsen or fail to improve within 1–2 weeks of conservative treatment, reassessment is necessary 1, 3
• Red-flag symptoms requiring immediate evaluation: Severe anorectal pain (suggests abscess, fissure, or strangulated prolapse), atypical bleeding patterns (maroon or dark blood, blood mixed with stool), significant bleeding with hemodynamic instability, or fever 2, 3
• Colonoscopy indications: Positive fecal occult blood testing, anemia, atypical bleeding patterns, or significant risk factors for colonic neoplasia 2, 3