Treatment

Hemorrhoids should only be treated in symptomatic patients.

• Indications: all patients with hemorrhoids

• Interventions to reduce anorectal pressure and straining

  • Lifestyle modifications [5]

    • High fiber diet (20–30 g/day)

    • Increased fluid intake

    • Avoidance of fatty foods

    • Regular physical activity

    • Avoidance of excessive straining

    • Limiting the amount of time spent on the toilet

  • Treatment of constipation with short-term (up to 1 week) use of stool softeners (e.g., docusate) or laxatives (e.g., polyethylene glycol 3350) as needed.

• Interventions to alleviate symptoms (e.g., pain, pruritus)

  • Sitz baths: a bath in which the buttocks are immersed in warm water for short periods of time

  • Topical medications for short-term symptomatic relief: topical anesthetics (e.g., lidocaine), corticosteroids (e.g., hydrocortisone), and/or vasoconstrictors (e.g., phenylephrine)

Conservative management is often the only intervention required for grade I–II internal hemorrhoids and external hemorrhoids.

Long-term use of topical medications for hemorrhoids can lead to sensitization and localized reactions and should be avoided.

• Indications: grade I–III internal hemorrhoids with symptoms refractory to medical management

• Interventions

  • Rubber band ligation: most common

    • A rubber band at the base of an internal hemorrhoid under vision through an anoscope

    • Ligation leads to ischemic necrosis with subsequent fibrosis.

  • Sclerotherapy: low risk of bleeding; consider for patients on anticoagulants

  • Infrared coagulation: application of infrared light waves to the base of the hemorrhoid under vision to induce necrosis and scar formation

• Potential complications: uncommon; can include bleeding, pain, or infection (including perianal sepsis)

• Indications

  • Symptomatic grade III and IV internal hemorrhoids

  • Symptomatic external hemorrhoids or combined external and internal hemorrhoids with prolapse

  • No improvement after, or inability to tolerate, medical and office-based interventions

• Options

  • Submucosal hemorrhoidectomy: surgical removal of hemorrhoids

    • Ferguson approach (closed approach): The mucosal defect is closed (healing by primary intention) after excision of the hemorrhoid. [6]

    • Milligan‑Morgan approach (open approach): The mucosal defect is kept open (healing by secondary intention) after excision of the hemorrhoid.

  • Stapled hemorrhoidopexy (Longo procedure)

    • A circular stapling device is used to remove a circular wedge of mucosal tissue above the dentate line

    • Only effective for internal hemorrhoids

  • Doppler-guided hemorrhoidal arterial ligation: identification and ligation of the arteries supplying hemorrhoids

• Potential complications: pain, bleeding, acute urinary retention, and rarely, anal stricture/stenosis

Perianal sepsis can occur after surgical or office-based interventions for hemorrhoids and may manifest with worsening pain, fever, or dysuria.