What is the recommended management of hemorrhoids in adults?

Management of Hemorrhoids in Adults

All hemorrhoid grades should begin with conservative management—increased dietary fiber (25–30 g daily), adequate water intake, and avoidance of straining—as first-line therapy, with office-based procedures (rubber band ligation) reserved for persistent grade I–III internal hemorrhoids, and surgical hemorrhoidectomy indicated for grade III–IV disease that fails conservative measures or presents with complications. 1

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Initial Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications:

• Increase fiber intake to 25–30 grams daily using bulk-forming agents such as psyllium husk (5–6 teaspoons mixed with 600 mL water daily) to soften stool and reduce straining 1
• Ensure adequate fluid intake to prevent constipation 1
• Avoid prolonged sitting and straining during defecation 1
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1

Pharmacological Adjuncts:

• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling through improved venous tone, though 80% of patients experience symptom recurrence within 3–6 months after cessation 1, 2
• 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 1, 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves a 92% resolution rate compared to 45.8% with lidocaine alone 1, 3

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Office-Based Procedures (For Persistent Grade I–III Internal Hemorrhoids)

When to Escalate:

• If conservative management fails after 6–8 weeks, proceed to office-based interventions 4

Rubber Band Ligation (Preferred First-Line Procedure):

• Most effective office-based procedure with success rates of 70.5–89% depending on hemorrhoid grade 1, 2
• The band must be placed ≥2 cm proximal to the dentate line to avoid severe pain 1, 3
• 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 clinicians prefer treating 1–2 columns at a time 1
• Long-term follow-up (10–17 years) shows ≈69% of patients remain asymptomatic 1
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1, 2

Complications of Rubber Band Ligation:

• Pain occurs in 5–60% of patients, typically mild and manageable with sitz baths and over-the-counter analgesics 1
• Other complications include abscess, urinary retention, band slippage, and prolapse/thrombosis of adjacent hemorrhoids (≈5% of patients) 1
• Severe bleeding may occur when the eschar sloughs, typically 1–2 weeks after treatment 1
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic infection 1

Alternative Office-Based Procedures:

• Injection sclerotherapy is suitable for first- and second-degree hemorrhoids, with an ≈89.9% improvement or cure rate, but has no proven superiority over conservative management alone 1
• Infrared photocoagulation shows success rates of 67–96% for grade I–II hemorrhoids but requires more repeat treatments than rubber band ligation 1

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Surgical Management (For Grade III–IV Hemorrhoids or Failed Conservative/Office-Based Therapy)

Indications for Hemorrhoidectomy:

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

Conventional Excisional Hemorrhoidectomy (Gold Standard):

• Lowest recurrence rate (2–10%) for grade III–IV hemorrhoids 1, 3, 2
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques with no significant difference in outcomes, though Ferguson may offer slightly improved wound healing 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2–4 weeks 1
• Complications include: urinary retention (2–36%), bleeding (0.03–6%), anal stenosis (0–6%), infection (0.5–5.5%), and incontinence (2–12%) 1
• Up to 12% of patients experience sphincter defects documented by ultrasonography and manometry 1

Techniques to Avoid:

• Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1, 3
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 3

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Management of Thrombosed External Hemorrhoids

Early Presentation (Within 72 Hours):

• Complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management 1, 3, 4
• Can be performed as an outpatient procedure with low complication rates 1
• Never perform simple incision and drainage—this leads to persistent bleeding and significantly higher recurrence rates; complete excision is required 1, 3, 4, 2

Late Presentation (>72 Hours):

• Conservative management is preferred as natural resolution has typically begun 1, 3, 2
• Treatment includes stool softeners, oral and topical analgesics (5% lidocaine), and sitz baths 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks achieves 92% resolution rate 1, 3

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Critical Diagnostic Considerations Before Treatment

Mandatory Colonoscopy Indications:

• 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, 3, 4
• Anemia from hemorrhoidal disease is rare (≈0.5 cases per 100,000 population)—chronic bleeding warrants complete colonic evaluation to exclude inflammatory bowel disease or colorectal cancer 1, 3, 4
• Patients aged ≥50 years or with colorectal cancer risk factors require colonoscopy before initiating hemorrhoid-specific treatment 1, 3
• Anal pain is generally NOT associated with uncomplicated hemorrhoids—its presence suggests anal fissure, abscess, or thrombosis 1, 4

Physical Examination:

• Anoscopy should be performed when feasible to directly visualize hemorrhoids and exclude other anorectal pathology 1, 4
• Digital rectal examination to assess for masses, fissures, or other pathology 1

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Special Populations

Pregnancy:

• Hemorrhoids occur in ≈80% of pregnant persons, more commonly during the third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely 1
• Hydrocortisone foam can be used safely in the third trimester with no adverse events compared to placebo 1

Portal Hypertension/Cirrhosis:

• Patients may have anorectal varices rather than true hemorrhoids—standard hemorrhoidectomy can cause life-threatening bleeding in this population 1, 4
• Conservative treatment is recommended, with bleeding managed with endoscopic techniques when possible 4

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Common Pitfalls to Avoid

• Never attribute anemia or chronic bleeding to hemorrhoids without colonoscopy, especially in older adults 1, 3, 4
• Never use topical corticosteroids for >7 days—prolonged use causes mucosal thinning and increases injury risk 1, 3, 4
• Never perform simple incision and drainage of thrombosed hemorrhoids—complete excision is mandatory if surgical intervention is chosen 1, 3, 4, 2
• 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—the benefit of early intervention declines after this period 1, 2