From the Guidelines
Treatment for hemorrhoids should start with non-operative management as the first-line therapy, focusing on dietary and lifestyle changes, such as increased fiber and water intake, and adequate bathroom habits, as recommended by the most recent guidelines 1.
Key Recommendations
- For patients with complicated hemorrhoids, non-operative management is the preferred initial approach, emphasizing dietary and lifestyle modifications 1.
- The use of flavonoids may be suggested to relieve symptoms in patients with complicated hemorrhoids, although the evidence is moderate and the recommendation is weak 1.
- Topical muscle relaxants might be considered for thrombosed or strangulated hemorrhoids, but the evidence is of low quality, leading to a weak recommendation 1.
- There is no clear recommendation for the use of NSAIDs, topical steroids, other topical agents, or injection of local anesthetics in the management of complicated hemorrhoids due to insufficient evidence 1.
Considerations for Treatment
- The decision to proceed with more invasive procedures such as rubber band ligation, sclerotherapy, infrared coagulation, or surgical removal (hemorrhoidectomy) should be made on a case-by-case basis, considering the severity of symptoms, failure of conservative management, and patient preferences 1.
- Surgical intervention is typically reserved for severe cases, including third-degree or fourth-degree hemorrhoids, or when there are complications or concomitant anorectal conditions requiring surgery 1.
Lifestyle and Dietary Changes
- Increasing fiber intake to 25-30 grams daily can help soften stool and reduce straining during bowel movements.
- Drinking plenty of water, aiming for 8-10 glasses daily, helps prevent constipation.
- Avoiding prolonged straining during bowel movements and adopting adequate bathroom habits are crucial in managing hemorrhoids.
Medical Procedures
- While office-based procedures like rubber band ligation, sclerotherapy, and infrared coagulation are options for hemorrhoid treatment, their role in complicated cases is not well-defined due to limited evidence 1.
- These procedures work by reducing blood flow to the hemorrhoid tissue or physically removing it, but their application should be guided by clinical judgment and patient-specific factors.
From the Research
Treatment Options for Hemorrhoids
- Medical management: stool softeners, topical over-the-counter preparations, topical nitroglycerine 2
- Dietary modifications: increased fiber and water intake 2, 3
- Behavioral therapies: sitz baths 2
- Office-based treatment: rubber band ligation for grades I to III internal hemorrhoids 2, 4
- Surgical treatment:
- Open or closed (conventional) excisional hemorrhoidectomy for recurrent or higher-grade disease 2
- Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices to decrease bleeding and pain 2
- Stapled hemorrhoidopexy to elevate grade III or IV hemorrhoids to their normal anatomic position 2, 3, 5
- Hemorrhoidal artery ligation for grade II or III hemorrhoids 2, 3
- Excision of thrombosed external hemorrhoids to reduce pain 2, 4
- Milligan-Morgan haemorrhoidectomy for grade IV haemorrhoids 3
- Mucopexy with or without mucosal resection for grade III haemorrhoids 3
- Laser, infrared photocoagulation, and stapling techniques for grade 3/4 hemorrhoids 5