What is the recommended management for hemorrhoids?

Hemorrhoid Management

First-Line Conservative Treatment for All Grades

All hemorrhoid patients should begin with dietary and lifestyle modifications, including increased fiber intake to 25-30 grams daily (achievable with 5-6 teaspoonfuls of psyllium husk in 600 mL water), adequate hydration, and avoidance of straining during defecation. 1, 2

• Bulk-forming agents like psyllium husk are safe and effective, with minimal systemic absorption 1
• Stool softeners help prevent constipation and reduce straining 1
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1

Topical Pharmacological Management

For Symptomatic Relief

Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution compared to 45.8% with lidocaine alone, making it the most effective topical treatment. 1, 2

• Nifedipine relaxes internal anal sphincter hypertonicity without systemic side effects 1
• Lidocaine provides immediate symptomatic relief of pain and itching 1
• Topical corticosteroids may reduce local inflammation but must be limited to ≤7 days maximum to avoid perianal tissue thinning 1, 2
• Topical nitrates show efficacy but are limited by high headache incidence (up to 50%) 1

Oral Pharmacological Adjuncts

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though 80% symptom recurrence occurs within 3-6 months after cessation 1, 3
• Over-the-counter analgesics (acetaminophen or ibuprofen) for additional pain control 1

Office-Based Procedures for Grade I-III Internal Hemorrhoids

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention when conservative management fails, with success rates of 70.5-89%. 1, 2

Rubber Band Ligation Technique

• Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Up to 3 hemorrhoids can be banded per session, though many limit to 1-2 columns 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Pain is the most common complication (5-60%), typically manageable with sitz baths and over-the-counter analgesics 1

Alternative Office Procedures

• Sclerotherapy is suitable for grade I-II hemorrhoids, with 70-85% short-term success but only one-third achieve long-term remission 1, 3
• 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

Contraindications to Office Procedures

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic infection 1
• Acutely thrombosed or irreducible hemorrhoids should not undergo office-based procedures 1

Management of Thrombosed External Hemorrhoids

Early Presentation (≤72 Hours)

Complete surgical excision under local anesthesia within 72 hours provides faster pain relief and markedly lower recurrence rates compared to conservative management. 1, 2, 3

• Excision should be performed as an outpatient procedure under local anesthesia 1
• The entire thrombosed hemorrhoid must be excised in one piece; simple incision and drainage is contraindicated due to persistent bleeding and higher recurrence 1, 2
• Wound is left open to heal by secondary intention 1

Late Presentation (>72 Hours)

Conservative management is preferred when presentation exceeds 72 hours, as natural resolution has typically begun. 1, 3

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1
• Stool softeners and oral analgesics 1
• Sitz baths for comfort 1

Surgical Hemorrhoidectomy Indications

Conventional excisional hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and hemorrhoids causing anemia. 1, 2

Surgical Technique Options

• Ferguson (closed) or Milligan-Morgan (open) techniques have comparable efficacy, with Ferguson potentially offering slightly improved wound healing 1
• Recurrence rate is only 2-10%, making it the most definitive treatment 1, 2, 3
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Stapled Hemorrhoidopexy

• Shows less postoperative pain and faster recovery than conventional hemorrhoidectomy 1
• Lacks long-term follow-up data and has reported complications including rectal perforation and pelvic sepsis 1
• Higher recurrence rate compared to conventional hemorrhoidectomy 4

Hemorrhoidal Artery Ligation (HAL/RAR)

• May result in less pain and faster recovery but with higher recurrence rates 4
• Suitable for grade II-III hemorrhoids 4

Procedures to Avoid

Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up and sphincter injuries. 1, 2

• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Critical Diagnostic Considerations

Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated. 1, 2

• Anemia from hemorrhoidal bleeding is rare (0.5 patients per 100,000 population) 1
• Anal pain is generally not associated with uncomplicated hemorrhoids; its presence suggests other pathology such as anal fissure (occurs in up to 20% of hemorrhoid patients) 1
• Colonoscopy is indicated when bleeding is atypical, no source is evident on anorectal examination, or significant risk factors for colonic neoplasia exist 1, 2

Special Population: Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, most commonly in the third trimester 5
• Conservative management with fiber, fluids, and bulk-forming agents is first-line 5
• Osmotic laxatives (polyethylene glycol or lactulose) are safe during pregnancy 5
• Hydrocortisone foam is safe in the third trimester with no adverse events compared to placebo 5
• Surgical excision of thrombosed hemorrhoids within 72 hours is appropriate when indicated 5

Common Pitfalls to Avoid

• Never assume all anorectal symptoms are due to hemorrhoids without proper evaluation 1, 2
• Never use corticosteroid creams for more than 7 days 1, 2
• Never perform simple incision and drainage of thrombosed hemorrhoids 1, 2
• Never delay definitive treatment when active bleeding has caused anemia 1
• Never attribute anemia to hemorrhoids without colonoscopic evaluation to rule out proximal colonic pathology 1