What medication regimen should be prescribed for an adult with uncomplicated internal or external hemorrhoids, assuming no contraindications?

Medication Regimen for Uncomplicated Hemorrhoids

For adults with uncomplicated internal or external hemorrhoids, start with fiber supplementation (25-30 grams daily), adequate hydration, and topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks, which achieves a 92% resolution rate. 1

First-Line Conservative Management

All hemorrhoid grades should begin with dietary and lifestyle modifications as the foundation of therapy, regardless of whether they are internal or external. 1

Dietary Modifications

• Increase dietary fiber 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 water intake throughout the day to prevent constipation and facilitate the fiber's effect. 1
• Avoid prolonged sitting and straining during defecation, as these worsen hemorrhoidal symptoms. 1

Topical Pharmacological Treatment

The most effective topical regimen is 0.3% nifedipine combined with 1.5% lidocaine ointment applied every 12 hours for two weeks, which works by relaxing internal anal sphincter hypertonicity and has no systemic side effects. 1

• Lidocaine 1.5-2% ointment or cream provides symptomatic relief of local pain and itching. 1
• Topical corticosteroids (hydrocortisone 1%) may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa. 1, 2
• Topical nitrates show good results but are limited by high incidence of headache (up to 50% of patients), making nifedipine the preferred topical muscle relaxant. 1

Oral Pharmacological Adjuncts

Flavonoids (phlebotonics such as diosmin/hesperidin) relieve bleeding, pain, and swelling through improvement of venous tone, but symptom recurrence reaches 80% within 3-6 months after cessation. 1, 3

• Over-the-counter oral analgesics (acetaminophen or ibuprofen) provide additional pain control when needed. 1
• Stool softeners help prevent straining during bowel movements. 3

Specific Considerations by Hemorrhoid Type

For Internal Hemorrhoids (Grade I-III)

• Conservative management with fiber, fluids, and topical therapy is appropriate for first-line treatment. 1
• If symptoms persist after 1-2 weeks of conservative therapy, consider office-based procedures such as rubber band ligation, which has success rates of 70.5-89%. 1

For External Hemorrhoids (Non-Thrombosed)

• External hemorrhoids typically require treatment only when symptomatic. 1
• The same conservative regimen applies: fiber, hydration, and topical 0.3% nifedipine with 1.5% lidocaine. 1

For Thrombosed External Hemorrhoids

Timing determines the treatment approach:

• Within 72 hours of symptom onset: Complete surgical excision under local anesthesia provides faster pain relief and lower recurrence rates compared to conservative management. 1, 3
• Beyond 72 hours: Conservative management is preferred with topical 0.3% nifedipine/lidocaine, stool softeners, oral analgesics, and sitz baths, as natural resolution has typically begun. 1, 3

Never perform simple incision and drainage of thrombosed hemorrhoids, as this leads to persistent bleeding and significantly higher recurrence rates. 1

Suppositories: Limited Role

Over-the-counter suppositories provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion. 1

• Topical analgesics in suppository form can relieve local pain and itching, though data supporting long-term efficacy are limited. 1
• Hydrocortisone suppositories should be applied for no more than 7 days to avoid perianal tissue thinning. 1
• Rectal 5-ASA (mesalamine) suppositories are more effective than hydrocortisone for symptom relief in internal hemorrhoids. 1

Critical Pitfalls to Avoid

• Never use corticosteroid creams for more than 7 days, as prolonged use causes thinning of perianal and anal mucosa, increasing injury risk. 1, 2
• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopic evaluation to rule out proximal colonic pathology. 1
• Avoid greasy topical products (such as coconut oil) in the perianal area, as they trap moisture and promote infection. 2
• Do not assume all anorectal symptoms are due to hemorrhoids alone; anal fissures occur in up to 20% of patients with hemorrhoids. 1

When to Reassess or Escalate Care

If symptoms worsen or fail to improve within 1-2 weeks of conservative treatment, reassessment is necessary to consider office-based procedures or alternative diagnoses. 1

• Significant bleeding, severe pain, or fever require urgent evaluation to rule out complications. 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients per 100,000 population) and warrants colonoscopy before attributing it to hemorrhoids. 1