What is the appropriate treatment for hemorrhoids (piles)?

Treatment for Hemorrhoids

All hemorrhoids should begin with conservative management—increased dietary fiber (25–30 g/day), adequate water intake, and avoidance of straining—as first-line therapy regardless of grade or severity. 1

Conservative Management (First-Line for All Grades)

Conservative therapy forms the foundation of hemorrhoid treatment and should be initiated in every patient before considering procedural or surgical options 1:

• Dietary fiber supplementation: 25–30 grams daily, achievable with 5–6 teaspoons of psyllium husk mixed with 600 mL water 1
• Adequate fluid intake to soften stool and reduce straining 1
• Lifestyle modifications: Avoid prolonged sitting and straining during defecation 1
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1

Topical Symptomatic Relief

• Topical lidocaine 1.5–2% provides relief of local pain and itching 1
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to prevent mucosal thinning 1
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution for thrombosed external hemorrhoids, compared to 45.8% with lidocaine alone 1

Oral Pharmacotherapy

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling by improving venous tone 1, 2, 3
  • Critical limitation: 80% symptom recurrence within 3–6 months after cessation 1
  • Diosmin specifically shortens acute flare resolution from 8 days to 4–5 days 3

Office-Based Procedures (Second-Line)

When conservative management fails after 1–2 weeks, office-based procedures are indicated for grades I–III internal hemorrhoids 1:

Rubber Band Ligation (Preferred)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I–III internal hemorrhoids 1:

• Success rates: 70.5–89% depending on hemorrhoid grade 1
• Long-term outcomes: ~69% remain asymptomatic at 10–17 years 1
• Technique: Band placed ≥2 cm proximal to dentate line to avoid severe pain 1
• Session limits: Up to 3 hemorrhoids can be banded per session, though many practitioners treat 1–2 columns at a time 1

Complications:

• Pain in 5–60% (usually mild, managed with sitz baths and OTC analgesics) 1
• Abscess, urinary retention, band slippage (~5%) 1
• Severe bleeding when eschar sloughs (1–2 weeks post-procedure) 1
• Contraindication: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to necrotizing pelvic infection risk 1

Alternative Office Procedures

• Injection sclerotherapy: Suitable for grades I–II hemorrhoids, ~89.9% improvement rate, but no proven superiority over conservative management alone 1
• Infrared photocoagulation: 67–96% success for grades I–II, but requires more repeat treatments than rubber band ligation 1
• Bipolar diathermy: 88–100% success for bleeding control in grade II hemorrhoids 1

Surgical Management (Third-Line)

Indications for Hemorrhoidectomy

Surgery is indicated when 1:

• Medical and office-based therapy have failed
• Symptomatic grade III–IV hemorrhoids
• Mixed internal and external hemorrhoids
• Concomitant conditions (fissure, fistula) requiring surgery
• Anemia from hemorrhoidal bleeding
• Patient preference after thorough discussion

Surgical Options

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:

• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 1
• Major drawback: Postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2–4 weeks 1
• Complications: Urinary retention (2–36%), bleeding (0.03–6%), anal stenosis (0–6%), infection (0.5–5.5%), incontinence (2–12%) 1

Procedures to avoid:

• Anal dilatation: 52% incontinence rate at 17-year follow-up; should be abandoned 1
• Cryotherapy: Prolonged pain, foul-smelling discharge, 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 lower recurrence rates compared to conservative management 1:

• Performed as outpatient procedure under local anesthesia 1
• Wound left open to heal by secondary intention 1
• Never perform simple incision and drainage—this leads to persistent bleeding and higher recurrence 1

Late Presentation (>72 Hours)

Conservative management is preferred when natural resolution has begun 1:

• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1
• Stool softeners and oral analgesics 1
• Topical corticosteroids ≤7 days maximum 1
• Pain typically resolves within 7–10 days 4

Critical Diagnostic Considerations

Do not attribute all anorectal symptoms to hemorrhoids without proper evaluation 1:

• Hemorrhoids alone do not cause positive fecal occult blood tests—colonoscopy required to exclude proximal pathology 1
• Anemia from hemorrhoids is rare (0.5 per 100,000 population)—colonoscopy mandatory to rule out inflammatory bowel disease or colorectal cancer 1
• Anal pain is generally NOT associated with uncomplicated hemorrhoids—suggests anal fissure (present in up to 20% of hemorrhoid patients), abscess, or thrombosis 1
• Anoscopy should be performed when feasible to visualize hemorrhoids and exclude other anorectal pathology 1

Special Populations: Pregnancy

Hemorrhoids occur in ~80% of pregnant persons, most commonly in the third trimester 4:

• Conservative management: Same as general population—fiber, fluids, bulk-forming agents (psyllium husk safe due to lack of systemic absorption) 4
• Osmotic laxatives (polyethylene glycol, lactulose) safe during pregnancy 4
• Hydrocortisone foam safe in third trimester with no adverse events versus placebo 4
• Avoid stimulant laxatives—conflicting safety data 4
• Thrombosed hemorrhoids within 72 hours: Surgical excision under local anesthesia provides faster resolution 4
• Acutely prolapsed/incarcerated hemorrhoids: May require emergency hemorrhoidectomy (~0.2% of pregnant women) 4

Treatment Algorithm by Grade

Grade I (bleeding only, no prolapse):

• Conservative management with fiber, fluids, lifestyle modifications 1
• If persistent: Rubber band ligation or sclerotherapy 1

Grade II (prolapse with spontaneous reduction):

• Conservative management first 1
• If persistent: Rubber band ligation (preferred), infrared photocoagulation, or bipolar diathermy 1

Grade III (prolapse requiring manual reduction):

• Conservative management trial 1
• If persistent: Rubber band ligation (70.5–89% success) 1
• If failed: Conventional hemorrhoidectomy 1

Grade IV (irreducible prolapse):

• Conventional excisional hemorrhoidectomy (2–10% recurrence rate) 1
• If acutely incarcerated/thrombosed: Emergency hemorrhoidectomy or excision with rubber band ligation 1

Common Pitfalls to Avoid

• Never use topical corticosteroids >7 days—causes mucosal thinning and increased injury risk 1
• Never perform simple incision and drainage of thrombosed hemorrhoids—complete excision required if surgical intervention chosen 1
• Never delay definitive treatment when active bleeding has caused anemia—natural history is continued blood loss 1
• Never perform rubber band ligation in immunocompromised patients—increased risk of necrotizing pelvic infection 1
• Never attribute anemia to hemorrhoids without colonoscopy—must exclude proximal colonic pathology 1