Treatment for Reducible Hemorrhoids
First-line treatment for reducible hemorrhoids is conservative management with dietary and lifestyle modifications—specifically increasing fiber intake to 25–30 grams daily, adequate water intake, and avoidance of straining during defecation—combined with flavonoids (phlebotonics) for symptom relief. 1, 2
Initial Conservative Management (Mandatory First Step)
All patients with reducible hemorrhoids—regardless of grade—should begin with non-operative therapy before considering procedural or surgical interventions. 1, 2
Dietary and Lifestyle Modifications
Increase dietary fiber to 25–30 grams daily, which can be achieved with 5–6 teaspoonfuls of psyllium husk mixed with 600 mL of water daily. 1, 2 Fiber softens stool, reduces straining, and decreases hemorrhoidal engorgement. 2
Adequate water intake is essential to complement fiber supplementation and prevent constipation. 1, 2
Avoid straining during defecation by establishing regular bowel habits and not delaying the urge to defecate. 2
Sitz baths (warm water soaks for 10–15 minutes, 2–3 times daily) reduce inflammation and provide symptomatic relief. 2
Pharmacological Adjuncts
Flavonoids (phlebotonics) are recommended to relieve bleeding, pain, and swelling by improving venous tone. 1, 3, 2 Evidence shows effectiveness for controlling acute bleeding in all grades of hemorrhoids. 3 However, symptom recurrence reaches 80% within 3–6 months after cessation, so they should be viewed as adjunctive rather than definitive therapy. 2, 4
Topical analgesics (e.g., lidocaine 1.5–2%) provide symptomatic relief of local pain and itching, though data supporting long-term efficacy are limited. 3, 2
Topical corticosteroid creams may ameliorate local perianal inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa. 1, 3, 2 Prolonged use is potentially harmful. 2
When to Escalate Beyond Conservative Management
If symptoms persist or worsen after 1–2 weeks of conservative therapy, or if there is significant bleeding, severe pain, or fever, further evaluation and procedural intervention are necessary. 2
Office-Based Procedures (Second-Line for Grades I–III)
Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I–III internal hemorrhoids after conservative management fails. 2 Success rates range from 70.5% to 89% depending on hemorrhoid grade, and it is more effective than sclerotherapy or infrared photocoagulation. 2, 4
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. 2
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. 2
Pain is the most common complication (5–60% of patients) but is typically minor and manageable with sitz baths and over-the-counter analgesics. 2
Contraindications include immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) due to increased risk of necrotizing pelvic infection. 2
Alternative office-based procedures include:
Sclerotherapy is suitable for first- and second-degree hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage. 2 Short-term efficacy is 70–85%, but long-term remission occurs in only one-third of patients. 4
Infrared photocoagulation has 67–96% success rates for grade I–II hemorrhoids but requires more repeat treatments. 2, 4
Surgical Management (Reserved for Refractory or Advanced Disease)
Hemorrhoidectomy is indicated for:
- Failure of medical and office-based therapy 2
- Symptomatic grade III or IV hemorrhoids 2, 4
- Mixed internal and external hemorrhoids 2
- Concomitant conditions (fissure, fistula) requiring surgery 2
Conventional excisional hemorrhoidectomy (Milligan-Morgan or Ferguson technique) is the most effective treatment overall, particularly for third-degree hemorrhoids, with a low recurrence rate of 2–10%. 2, 4 However, postoperative pain requiring narcotic analgesics is a major drawback, and most patients do not return to work for 2–4 weeks. 2
Management of Thrombosed External Hemorrhoids (Special Consideration)
If a reducible hemorrhoid becomes acutely thrombosed:
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, 4
Beyond 72 hours: Conservative management is preferred, as natural resolution has typically begun. Treatment includes stool softeners, oral and topical analgesics (e.g., 5% lidocaine), and topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate). 1, 2, 4
Never perform simple incision and drainage of the thrombus alone, as this leads to persistent bleeding and higher recurrence rates. 1, 2
Critical Pitfalls to Avoid
Do not attribute all rectal bleeding to hemorrhoids without proper evaluation. 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. 2 Colonoscopy is warranted if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination. 1, 2
Do not use corticosteroid creams for more than 7 days, as prolonged use causes thinning of perianal and anal mucosa, increasing risk of injury. 1, 3, 2
Avoid anal dilatation due to a 52% incontinence rate at 17-year follow-up and sphincter injuries. 2
Avoid cryotherapy due to prolonged pain, foul-smelling discharge, and greater need for additional therapy. 2