Management of Symptomatic Hemorrhoids
All symptomatic hemorrhoids should begin with conservative management—increased dietary fiber (25–30 g/day), adequate water intake, and avoidance of straining—regardless of grade or severity. 1, 2
Classification Framework
Internal hemorrhoids are graded by degree of prolapse: 1
- Grade I: Bleeding without prolapse
- Grade II: Prolapse with spontaneous reduction
- Grade III: Prolapse requiring manual reduction
- Grade IV: Irreducible prolapse
External hemorrhoids arise below the dentate line and cause symptoms only when thrombosed, presenting with acute pain and a palpable perianal mass. 1
Conservative Management (First-Line for All Grades)
Dietary and Lifestyle Modifications
- Increase fiber intake to 25–30 grams daily using psyllium husk (5–6 teaspoons with 600 mL water daily) to produce soft, bulky stools and reduce straining. 1, 2
- Ensure adequate fluid intake to prevent constipation and facilitate stool passage. 1, 2
- Avoid prolonged sitting and straining during defecation. 1
Pharmacological Adjuncts
- Flavonoids (phlebotonics) relieve bleeding, pain, and swelling by improving venous tone, but 80% of patients experience symptom recurrence within 3–6 months after cessation. 1, 3
- Topical lidocaine 1.5–2% provides symptomatic relief of local pain and itching. 1
- Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid mucosal thinning and tissue injury. 1, 2
Special Topical Therapy for External Hemorrhoids
- Topical 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves a 92% resolution rate compared to only 45.8% with lidocaine alone, with no systemic side effects. 1, 2
- This combination works by relaxing internal anal sphincter hypertonicity, which contributes to pain. 1
Office-Based Procedures (After Conservative Failure)
Rubber Band Ligation (First-Line Procedural Treatment)
Rubber band ligation is the most effective office-based procedure for persistent grade I–III internal hemorrhoids, with success rates of 70.5–89%. 1, 3
- The band must be placed ≥2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerves are absent above the anal transition zone. 1
- Can be performed in an office setting without anesthesia using suction devices. 1
- Up to three hemorrhoidal columns may be banded in a single session, though many practitioners treat only 1–2 columns at a time. 1
- More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation. 1
Complications:
- Pain (5–60% of patients), typically mild and manageable with sitz baths and over-the-counter analgesics. 1
- Severe bleeding when the eschar sloughs (typically 1–2 weeks post-treatment). 1
- Necrotizing pelvic sepsis is rare but serious, with increased risk in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes). 1
Alternative Office Procedures
- Injection sclerotherapy is suitable for grade I–II hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage, with 70–85% short-term efficacy but only one-third achieving long-term remission. 1, 3
- Infrared photocoagulation has 67–96% success rates for grade I–II hemorrhoids but requires more repeat treatments than rubber band ligation. 1, 3
- Bipolar diathermy achieves 88–100% success for bleeding control in grade II hemorrhoids. 1
Surgical Management
Indications for Hemorrhoidectomy
Surgical hemorrhoidectomy is indicated for: 1, 4
- Failure of medical and office-based therapy
- Symptomatic grade III–IV hemorrhoids
- Mixed internal and external hemorrhoids
- Concomitant anorectal conditions requiring surgery (fissure, fistula)
- Anemia from hemorrhoidal bleeding
Surgical Techniques
- Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) is the most effective treatment overall, particularly for grade III–IV hemorrhoids, with recurrence rates of only 2–10%. 1, 3
- The Ferguson (closed) technique may offer slightly improved wound healing and reduced postoperative pain compared to the open technique. 1
- Major drawback: Postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2–4 weeks. 1
Techniques to Avoid
- Anal dilatation should be abandoned due to a 52% incontinence rate at 17-year follow-up and sphincter injuries. 1
- Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy. 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 therapy. 1, 2, 3
- The entire thrombosed hemorrhoid should be excised in one piece; the wound is left open to heal by secondary intention. 1
- Simple incision and drainage is contraindicated because it leads to persistent bleeding and significantly higher recurrence rates. 1, 2
Late Presentation (>72 Hours)
Conservative management is preferred after 72 hours, as spontaneous resolution typically begins. 1, 2
- Use topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks. 1, 2
- Stool softeners, oral analgesics (acetaminophen or ibuprofen), and sitz baths provide additional comfort. 1
Critical Diagnostic Considerations
When to Perform Colonoscopy
Hemorrhoids alone do not cause positive fecal occult blood tests; colonoscopy is required to exclude proximal colonic pathology before attributing bleeding or anemia to hemorrhoids. 1
- Anemia due to hemorrhoidal disease is rare (≈0.5 cases per 100,000 population). 1
- Colonoscopy is indicated for patients aged ≥50 years, those with colorectal cancer risk factors, or when bleeding is atypical. 1, 4
Red Flags Suggesting Alternative Diagnosis
- Anal pain is generally not associated with uncomplicated internal hemorrhoids; its presence suggests anal fissure (occurs in up to 20% of patients with hemorrhoids), abscess, or thrombosis. 1
- Off-midline fissures require immediate evaluation for Crohn's disease, HIV/AIDS, ulcerative colitis, tuberculosis, syphilis, leukemia, or cancer. 1
Common Pitfalls to Avoid
- Never use topical corticosteroids for more than 7 days, as prolonged use causes mucosal thinning and increases injury risk. 1, 2
- Never perform simple incision and drainage of thrombosed hemorrhoids; complete excision is required if surgical intervention is chosen. 1, 2
- Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopic evaluation. 1
- Avoid rubber band ligation in immunocompromised patients due to increased risk of necrotizing pelvic infection. 1
- Do not delay surgical excision of thrombosed external hemorrhoids beyond 72 hours, as the benefit of early intervention declines after this period. 1
Referral Indications
Refer to a colorectal surgeon when: 4
- Conservative management has failed despite adequate trial
- Symptomatic grade III–IV or mixed internal and external hemorrhoids
- Recurrent thrombosis or persistent symptoms despite conservative management
- Concomitant anorectal conditions requiring surgery