Hemorrhoids Treatment & Management

Treat hemorrhoids only when the patient complains of them. The old adage that it is hard to make an asymptomatic patient better applies here. No matter how bad the hemorrhoids look to the practitioner, they should not be treated unless they bother the patient.

Treatment of hemorrhoids is divided by the cause of symptoms, into internal and external treatments. Accurately classifying a patient's symptoms and the relation of the symptoms to internal and external hemorrhoids is important.

Internal hemorrhoids

Internal hemorrhoids do not have cutaneous innervation and can therefore be destroyed without anesthetic, and the treatment may be surgical or nonsurgical. Internal hemorrhoid symptoms often respond to increased fiber and liquid intake and to avoidance of straining and prolonged toilet sitting. Nonoperative therapy works well for symptoms that persist despite the use of conservative therapy. Most nonsurgical procedures currently available are performed in the clinic or ambulatory setting.

The following is a quick summary of treatment for internal hemorrhoids by grade:

• Grade I hemorrhoids are treated with conservative medical therapy and avoidance of nonsteroidal anti-inflammatory drugs (NSAIDs) and spicy or fatty foods
• Grade II or III hemorrhoids are initially treated with nonsurgical procedures
• Very symptomatic grade III and grade IV hemorrhoids are best treated with surgical hemorrhoidectomy
• Treatment of grade IV internal hemorrhoids or any incarcerated or gangrenous tissue requires prompt surgical consultation

Stapled hemorrhoid surgery, or procedure for prolapsing hemorrhoids (PPH), is an excellent alternative for treating internal hemorrhoids that have not been amenable to conservative or nonoperative approaches. Short- and medium-term results are excellent. Patients with minimal external tags and large internal hemorrhoids are easily treated with procedure for prolapsing hemorrhoids and skin tag excision. Operative resection is sometimes required to control the symptoms of internal hemorrhoids.

External hemorrhoids

External hemorrhoid symptoms are generally divided into problems with acute thrombosis and hygiene/skin tag complaints. The former respond well to office excision (not enucleation), whereas operative resection is reserved for the latter. Remember that therapy is directed solely at the symptoms, not at aesthetics.

When performed well, operative hemorrhoidectomy should have a 2-5% recurrence rate. Nonoperative techniques, such as rubber band ligation, produce recurrence rates of 30-50% within 5-10 years. However, these recurrences can usually be addressed with further nonoperative treatments.^[13] Long-term results from procedure for prolapsing hemorrhoids are unavailable at this time.^{[14, 15, 16]}

Controversies

The major controversies regarding the treatment of hemorrhoids center on the indications for treatment and the choice of operative versus nonoperative therapy. Most experienced surgeons are using office-based nonoperative therapies and are relying less on operative hemorrhoidectomy than they previously were. In the United States, rubber band ligation (compared with injection sclerotherapy) is the mainstay of conservative treatment. Procedure for prolapsing hemorrhoids (PPH), which has been gaining increasing favor in the United States, provides an excellent alternative to operative hemorrhoidectomy for patients with minimal external disease and large internal hemorrhoids.

Acutely thrombosed external hemorrhoids may be safely excised in the emergency department in patients who present within 48-72 hours of symptom onset. (See Thrombosed External Hemorrhoid Excision)

Infiltration of a local anesthetic containing epinephrine is followed by elliptical incision and excision of the thrombosed hemorrhoid and overlying skin. Simple incision and clot evacuation is inadequate therapy and should not be performed.

The incision should not extend beyond the anal verge or deeper than the cutaneous layer. A pressure dressing is applied for several hours, after which time the wound is left to heal by secondary intention.

In patients presenting after 72 hours from the start of symptoms, conservative medical therapy is preferable. (See Conservative Management.)

Medical management is the initial treatment of choice for grade I internal and nonthrombosed external hemorrhoids. It consists of warm baths (twice or thrice daily [bid/tid]); a high-fiber diet^[17] ; adequate fluid intake; stool softeners; topical and systemic analgesics; proper anal hygiene; and in some cases, a short course of topical steroid cream.

Retraining the patient's toilet habit is also a consideration. Decreasing straining and constipation shrinks internal hemorrhoids and decreases their symptoms; therefore, first-line treatment of all first- and second-degree (and many third- and fourth-degree) internal hemorrhoids should include measures to decrease straining and constipation.

Many patients see improvement or complete resolution of their symptoms with conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after 1 month of conservative therapy. Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids.

Warm baths

Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis.

Some authors do not suggest mechanisms such as the sitz bath for symptom relief. The rigid structure of these portable bathing apparatuses can act in a similar fashion as a toilet seat, causing venous congestion in the perianal area and potentially exacerbating the problem. However, sitz baths do have a role in the treatment of older or immobile patients who cannot routinely get in and out of a bathtub.

High-fiber diet

Psyllium seed significantly decreases bleeding and pain compared with placebo. Psyllium seed (Metamucil) and methylcellulose (Citrucel) are the most commonly used supplements. The average American diet consists of 8-15 g of fiber per day; a high-fiber diet includes more than 25 g of fiber per day. Many hemorrhoidal symptoms resolve only when they are treated with dietary alterations, including increased fiber and the addition of fiber supplements.

Antidiarrheal agents, toilet habit retraining, and stool softeners

Antidiarrheal agents are sometimes required in patients with hemorrhoidal symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids.

Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints. Suppositories, except for providing lubrication, also have a small role in the treatment of hemorrhoidal symptoms.

Topical agents

The use of topical steroids has not been well-studied in the treatment of thrombosed hemorrhoids; however, these agents can be used to decrease symptoms of pruritus and inflammation. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. It is important to consider the principles of steroid use and the associated side effects, such as mucosal atrophy. As such, the prolonged use of topical steroids should be avoided.

Some authors rarely recommend typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. Submucosal veins do not get smaller with anti-inflammatory medications.

Topical nitroglycerine and nifedipine have also been used to relieve symptoms associated with anal sphincter spasm.^{[18, 19]} These agents should also be used with caution because of associated side effects, such as hypotension. Good evidence suggests that high-fiber diets in particular help reduce severity and duration of symptoms.

Numerous nonoperative methods to destroy internal hemorrhoids are available. Nonsurgical techniques function by rubber band ligation, ablation, sclerosis, or necrosis of mucosal tissues.^{[20, 21, 22]} Despite several meta-analyses and considerable personal preference, there is no clear advantage of one technique over the others; however, all should be the first-line treatment of all first- and second-degree internal hemorrhoids that do not respond to conservative therapy. All nonoperative treatments have approximately similar efficacy when administered by an experienced clinician.

Lord dilatation, in which the anal canal is manually stretched under anesthesia, is seldom used in the United States, and many colorectal surgeons condemn its use, because it is essentially an uncontrolled disruption of the sphincter mechanism.

Contraindications for nonsurgical techniques

The following conditions are contraindications for performing the nonsurgical procedures mentioned above:

• Acquired immunodeficiency syndrome (AIDS): Human immunodeficiency virus (HIV) infection and anal disease often occur together—conservative therapy is suggested, especially if immunosuppression is evident; poor healing occurs with low CD4 counts, especially when less than 200 cells/mm³
• Immunodeficiency disorders
• Coagulopathy
• Irritable bowel disease
• Pregnancy: This condition is associated with many anorectal complaints; nonoperative treatment or office thrombectomy usually relieves complaints, although operative hemorrhoidectomy is safe in pregnant women^[23]
• Immediate postpartum period
• Rectal wall prolapse
• Large anorectal fissure or infection
• Tumor

Rubber band ligation

Rubber band ligation is the most-used remedy for grade II and grade III hemorrhoids and is the standard by which other methods are compared. This procedure is most common in the United States, because it is the most commonly taught method in training programs.^[13] With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively.

Blaisdell^[24] and Barron^[25] described and refined ligation therapy. A band ligature is passed through an anoscope and placed on the rectal mucosa proximal to the dentate line. The tissue necroses and sloughs off in 1-2 weeks, leaving an ulcer that later fibroses. No anesthesia is required; complications are uncommon and usually benign.

When Jutabha et al compared endoscopic rubber band ligation with bipolar electrocoagulation for chronically bleeding grade II or III internal hemorrhoids that were unresponsive to medical therapy, ligation controlled rectal bleeding and other symptoms with significantly fewer treatments (2.3 ± 0.2) and had a significantly higher success rate (92%) than electrocoagulation (3.8 ± 0.4 and 62%, respectively).^[26] However, severe pain during treatment occurred more often with ligation (8%) than with electrocoagulation (0%), albeit treatment failure and crossovers were significantly less frequent (8% vs 38%).

Necrotizing pelvic sepsis is a rare, but serious, complication of rubber band ligation. The diagnosis is suggested by the triad of severe pain, fever, and urinary retention. It occurs 1-2 weeks after ligation, frequently in immune-compromised patients, and requires prompt surgical debridement.

Coagulation, electrocautery, and electrotherapy

Infrared coagulation serves best for grades I and II and some grade III hemorrhoids. This method may be as effective as banding with fewer and less severe complications.

Bipolar electrocautery is best for lower-grade hemorrhoids; this technique quickly coagulates the hemorrhoid tissue but has no effect on prolapse.

Low-voltage direct current works best for higher-grade hemorrhoids. Low-voltage direct current requires grounding time and provides excellent control of pain.

Sclerotherapy and cryotherapy

Sclerotherapy can provide adequate treatment of early internal hemorrhoids.^{[27, 28]} However, sclerotherapy and cryotherapy are infrequently used and generally reserved for grade I or II hemorrhoids. Although minimally invasive, these treatment methods have a higher rate of postprocedure pain. Impotence, urinary retention, and abscess formation have also been reported. Recurrence rates are as high as 30%.

Laser therapy and radiowave ablation

Laser therapy is more costly and provides no advantage over other methods. Operators must control the laser to avoid bleeding.

Radiowave ablation followed by suture ligation could prove to be a safe, cost-effective, and convenient way to treat prolapsing hemorrhoids.^[29]

Many patients have been referred for surgery because they have severely swollen prolapsed hemorrhoids or very large external skin tags. When questioned, the patients are asymptomatic. Treat hemorrhoids only if they cause problems for the patient. Similarly, patients often ask when they should have surgery. Remind them that their hemorrhoids do not bother anyone else, and they should opt for aggressive treatment only when symptoms become bothersome.

Treatment guidelines are available from the American Gastroenterological Association (AGA)^[30] and the American Society of Colon and Rectal Surgeons (ASCRS).^[31]

Patients with ulcerative colitis can tolerate aggressive surgery if it is needed. Treat underlying acute disease before any elective anorectal surgery. Avoid aggressive treatment in patients with Crohn disease, especially if the rectal mucosa is acutely inflamed. Drain abscesses as soon as possible, despite active disease elsewhere. If necessary, operative hemorrhoidectomy is safe in pregnant women.^[23]

Hemorrhoid surgery can usually be performed using local anesthesia with intravenous (IV) sedation. Regional or general anesthetic techniques also are used. Routine preoperative workup for these techniques is required. Simple distal rectal evacuation is required for a clean operative field. Distal rectal evacuation is best achieved by small-volume saline enemas.

Excision of thromboses

External hemorrhoids generally elicit symptoms due to acute thromboses, recurrent thromboses, or hygiene problems. Manage acute thromboses and recurrent thromboses in a similar fashion. Identify the offending vascular cluster. In the office or clinical setting, inject local anesthetic, and then perform excision of the overlying skin and underlying veins.

Enucleation of the thrombosis alone can result in recurrence of the hemorrhoid at the same spot; excision of the underlying vein completely prevents this event. Electrocoagulation or topical astringent (Monsel solution) provides hemostasis. Suturing the wound closed is not necessary and may cause more pain. Remember, acute thromboses spontaneously resolve in 10-14 days; therefore, a patient who presents late and has diminishing pain is best left alone. Recurrence occurs up to 50% of the time when thromboses are left alone.

Surgical hemorrhoidectomy

Surgical hemorrhoidectomy is the most effective treatment for all hemorrhoids and in particular is indicated in the following situations:

• Conservative or nonsurgical treatment fails (persistent bleeding or chronic symptoms)
• Grade III and IV hemorrhoids with severe symptoms
• Presence of concomitant anorectal conditions (eg, anal fissure or fistula, hygiene trouble caused by large skin tags, a history of multiple external thromboses, or internal hemorrhoid trouble) requiring surgery
• Patient preference

About 5-10% of people with hemorrhoids eventually require surgical hemorrhoidectomy. Proper anesthetic care (especially if local anesthesia with supplementary IV sedation), attention to perioperative fluid restriction, and careful postoperative instructions can ease the patient's recovery.

Postoperative pain remains the major complication, with most patients requiring 2-4 weeks before returning to normal activities. Other possible complications include urinary retention, anal stenosis, and incontinence.

Nonlaser versus laser hemorrhoidectomy

Laser hemorrhoidectomy, as opposed to conventional scalpel and electrocautery techniques, is associated with many myths. Hemorrhoidectomy factories have touted painless or decreased pain and shortened healing times as advantages to performing hemorrhoidectomies by laser. No documented studies support these claims. In fact, one prospective study found no difference between scalpel and laser hemorrhoidectomy.^[32] The reader is referred to appropriate textbooks to see descriptions of techniques used.^{[33, 34]}

Stapled hemorrhoid surgery/ procedure for prolapsing hemorrhoids (PPH)

Stapled hemorrhoid surgery, or PPH, was first described in 1997-1998 and has become prominent.^{[35, 36, 14]} This procedure is mainly used to treat internal hemorrhoids that are not amenable to conservative and nonoperative therapies. PPH is suggested for patients with large internal hemorrhoids and minimal external component. This procedure can be done in an outpatient setting with local anesthesia,^{[37, 38, 39, 40]} similar to the protocol used for conventional hemorrhoid surgery. Narcotic use and recovery is significantly decreased compared with conventional operative hemorrhoid surgery.

During this procedure, a specially designed circular stapler with smaller staples is used. The technique involves placing a suture in the mucosal and submucosal layers circumferentially, approximately 3-4 cm above the dentate line. The stapler is placed and slowly closed around the purse string. Care is taken to draw excess internal hemorrhoidal tissue into the stapler. The stapler is fired, resecting the excess tissue and placing a circular staple line above the dentate line, resulting in resection of excessive internal hemorrhoidal tissue, pexy of the internal hemorrhoidal tissue left behind, and interruption of the blood supply from above.

PPH does not directly affect the external tissue. Reports have described shrinking of external hemorrhoidal tissue after PPH, probably from decreased blood flow. Good results from PPH combined with judicial excision of occasional skin tags also have been reported.

Acute hemorrhoidal crisis

Acute hemorrhoidal crisis is a rare event that usually requires emergency treatment. The mechanism of action is a large internal hemorrhoid prolapse. The sphincter mechanism squeezes, incarcerating the internal hemorrhoids and strangulating them. The resulting spasm causes edema and occasionally thrombosis of the external hemorrhoids. The resulting pain and swelling are dramatic and very painful. Emergent operative resection is safe and, with conservation of the anoderm, provides good relief. Rapid pain relief with office excision of thromboses and ligation of internal hemorrhoids has been reported.

After excision of a thrombosed external hemorrhoid, the patient may be discharged home for several hours of bedrest followed by warm baths 2-3 times daily, stool softeners, and topical or systemic analgesia. The patient should return in 48-72 hours for a wound check.

All other patients should be referred to a surgical or rectal clinic for more definitive treatment and sent home with conservative medical therapy.

Monitor patients at regular intervals until they are healed and have no symptoms.

Attention to regular and soft bowel movements is important. Bulk agents (eg, psyllium seed) and oral fluids are important. Bathing in tubs for comfort and hygiene is part of the routine. Judicious narcotic administration relieves pain.^[41] Patients should also be advised of the following:

• Avoid constipation
• Weight loss
• Avoid prolonged sitting on the toilet
• Avoid prolonged sitting at work
• Improved anorectal hygiene