What is the recommended treatment approach for symptomatic internal and external hemorrhoids in adults?

Treatment of Hemorrhoids

First-Line Conservative Management for All Grades

All patients with symptomatic hemorrhoids should begin with dietary and lifestyle modifications, regardless of hemorrhoid grade or severity. 1, 2

• Increase dietary fiber intake to 25-30 grams daily, achievable with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL water daily 1, 2
• Substantially increase water intake to soften stool and reduce straining 3, 1
• Avoid straining during defecation and limit time on toilet to 3 minutes 1
• Take regular warm sitz baths to reduce inflammation and discomfort 1, 2

Flavonoids (phlebotonics) are the most effective pharmacological option for controlling acute hemorrhoidal bleeding, relieving bleeding, pain, and swelling in all grades. 1 However, symptom recurrence reaches 80% within 3-6 months after cessation, so they should be combined with dietary modifications 1, 4

Topical Treatments

• Topical analgesics (lidocaine 1.5-2%) provide symptomatic relief of local pain and itching 1, 2
• Topical corticosteroids may reduce perianal skin irritation, but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 3, 1, 2
• For external hemorrhoids or thrombosed hemorrhoids: topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate compared to 45.8% with lidocaine alone 1, 2, 5

Office-Based Procedural Treatment for Internal Hemorrhoids

When conservative management fails after 1-2 weeks, rubber band ligation is the first-line procedural intervention for grades I-III internal hemorrhoids, with success rates of 70.5-89%. 1, 2

Rubber Band Ligation Technique

• Place the band at least 2 cm proximal to dentate line to avoid severe pain 1, 2
• Can treat up to 3 hemorrhoids in a single session, though many practitioners limit to 1-2 columns at a time 2
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 2

Alternative Office Procedures

• Injection sclerotherapy: suitable for first and second-degree hemorrhoids, with 70-85% short-term efficacy but only one-third achieve long-term remission 2, 4
• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, with 70-80% success in reducing bleeding and prolapse 2, 4
• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 2
• Cryotherapy is no longer recommended due to high complication rate, prolonged pain, and foul-smelling discharge 3, 2

Surgical Management

Excisional hemorrhoidectomy is indicated when bleeding has caused anemia, when conservative and office-based therapies have failed, or for symptomatic grade III-IV hemorrhoids, with a 2-10% recurrence rate. 1, 2

Indications for Surgery

• Failure of medical and non-operative therapy 3, 2
• Symptomatic grade III-IV hemorrhoids 3, 2
• Mixed internal and external hemorrhoids 3, 2
• Anemia from hemorrhoidal bleeding 1, 2
• Concomitant anorectal conditions (fissure, fistula) requiring surgery 3, 2

Surgical Techniques

Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) achieves 90-98% success rates. 1, 2

• Ferguson (closed) technique may offer slightly improved wound healing and reduced postoperative pain compared to Milligan-Morgan (open) technique 2
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 2
• Anal dilatation should never be performed due to 52% incontinence rate at 17-year follow-up 3, 2

Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours)

For thrombosed external hemorrhoids presenting within 72 hours, complete surgical excision under local anesthesia provides faster pain relief and significantly lower recurrence rates compared to conservative management. 1, 2, 5

• Perform complete excision of the entire thrombosed hemorrhoid in one piece 2, 5
• Never perform simple incision and drainage—this leads to persistent bleeding and significantly higher recurrence rates 1, 2, 5
• Can be performed as outpatient procedure under local anesthesia 2

Late Presentation (>72 Hours)

For presentation beyond 72 hours, conservative management is preferred as natural resolution has typically begun. 1, 2

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1, 2
• Stool softeners and oral analgesics (NSAIDs or acetaminophen) 1, 2
• Topical corticosteroids for ≤7 days maximum 1, 2

Critical Diagnostic Considerations

Anemia from hemorrhoidal disease is rare (0.5 patients per 100,000 population), and fecal occult blood positivity should prompt colonoscopy. 1, 2

• Hemorrhoids alone do not cause positive stool guaiac tests 2
• Significant anal pain is not typical of uncomplicated hemorrhoids and suggests alternative pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids) or abscess 1, 2
• All patients who report rectal bleeding should undergo sigmoidoscopy 3
• Evaluate proximal colon by colonoscopy if bleeding is not typical of hemorrhoids (dark blood or blood mixed in feces), guaiac-positive stools, or anemia present 3, 1

When to Refer for Specialist Evaluation

Immediate referral is indicated for:

• Anemia from hemorrhoidal bleeding 1
• Severe bleeding with hemodynamic instability (dizziness, tachycardia, hypotension) 1, 5
• Symptoms persisting >1-2 weeks despite appropriate conservative treatment 1
• Grade IV hemorrhoids (always require surgical evaluation) 1
• Severe pain with high fever and urinary retention (suggests necrotizing pelvic sepsis) 2, 5

Special Populations and Considerations

Patients with portal hypertension or cirrhosis may have anorectal varices rather than true hemorrhoids, and standard hemorrhoidectomy can cause life-threatening bleeding in this population. 1, 2

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during third trimester 2
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, and osmotic laxatives (polyethylene glycol or lactulose) 2
• Hydrocortisone foam can be used safely in third trimester 2

Common Pitfalls to Avoid

• Delaying definitive treatment when active bleeding has caused anemia leads to continued blood loss 1, 2
• Using corticosteroid creams for more than 7 days causes perianal tissue thinning and increased injury risk 1, 2
• Assuming all anorectal symptoms are due to hemorrhoids without proper examination 2
• Performing rubber band ligation on external or thrombosed hemorrhoids (causes severe pain when applied below dentate line) 2
• Attributing anemia to hemorrhoids without colonoscopic evaluation to exclude proximal colonic pathology 1, 2