UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate®

Home and office treatment of symptomatic hemorrhoids

Authors
Ronald Bleday, MD
Elizabeth Breen, MD
Section Editor
Martin Weiser, MD
Deputy Editor
Wenliang Chen, MD, PhD

INTRODUCTION

Hemorrhoids are collections of submucosal, fibrovascular, arteriovenous sinusoids that are part of the normal anorectum [1]. In epidemiologic studies conducted in Korea, England, and Austria, between 14 and 39 percent of the population had hemorrhoids; however, many were without symptoms [2-4]. Hemorrhoids without any symptoms do not require treatment.

By contrast, an estimated 10 million people in the United States complained of hemorrhoids, corresponding to a prevalence of 4.4 percent [5]. The most common complaint associated with hemorrhoidal disease is painless rectal bleeding during defecation with or without tissue prolapse. Other typical symptoms include anal pruritus or pain and a lump at the anal verge due to thrombosis or strangulation [2]. (See "Hemorrhoids: Clinical manifestations and diagnosis", section on 'Clinical manifestations'.)

Those presenting to their physicians for symptomatic hemorrhoids probably represent a group with relatively severe disease. Because a large variety of over-the-counter products are available and marketed for the treatment of hemorrhoids, patients often self-diagnose and self-treat before seeking medical attention. Incidentally, the quality of information about hemorrhoids on the internet is highly variable, and a significant proportion of websites assessed are poorly informed (40 percent in one study [6]).

Several options are available for the treatment of symptomatic hemorrhoids, and most patients with low-grade internal hemorrhoids will have relief with home-based conservative treatment or office-based procedures that are reviewed in this topic. Surgery is indicated for low-grade hemorrhoids that are refractory to home- or office-based treatments, high-grade hemorrhoids, and complicated hemorrhoids. Surgical treatment of hemorrhoids is reviewed separately. (See "Surgical treatment of hemorrhoidal disease".)

CLASSIFICATION OF HEMORRHOIDS

Hemorrhoids are classified relative to their relationship to the dentate line (figure 1):

                                

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Aug 2017. | This topic last updated: Aug 16, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
References
Top
  1. Jacobs D. Clinical practice. Hemorrhoids. N Engl J Med 2014; 371:944.
  2. Lohsiriwat V. Treatment of hemorrhoids: A coloproctologist's view. World J Gastroenterol 2015; 21:9245.
  3. Gazet JC, Redding W, Rickett JW. The prevalence of haemorrhoids. A preliminary survey. Proc R Soc Med 1970; 63 Suppl:78.
  4. Riss S, Weiser FA, Schwameis K, et al. The prevalence of hemorrhoids in adults. Int J Colorectal Dis 2012; 27:215.
  5. Johanson JF, Sonnenberg A. The prevalence of hemorrhoids and chronic constipation. An epidemiologic study. Gastroenterology 1990; 98:380.
  6. Yeung TM, D'Souza ND. Quality analysis of patient information on surgical treatment of haemorrhoids on the internet. Ann R Coll Surg Engl 2013; 95:341.
  7. Cusano F, Luciano S. Contact dermatitis from pramoxine. Contact Dermatitis 1993; 28:39.
  8. Kawada A, Noguchi H, Hiruma M, et al. Fixed drug eruption induced by lidocaine. Contact Dermatitis 1996; 35:375.
  9. Alonso-Coello P, Guyatt G, Heels-Ansdell D, et al. Laxatives for the treatment of hemorrhoids. Cochrane Database Syst Rev 2005; :CD004649.
  10. Moesgaard F, Nielsen ML, Hansen JB, Knudsen JT. High-fiber diet reduces bleeding and pain in patients with hemorrhoids: a double-blind trial of Vi-Siblin. Dis Colon Rectum 1982; 25:454.
  11. Rivadeneira DE, Steele SR, Ternent C, et al. Practice parameters for the management of hemorrhoids (revised 2010). Dis Colon Rectum 2011; 54:1059.
  12. Perez-Miranda M, Gomez-Cedenilla A, León-Colombo T, et al. Effect of fiber supplements on internal bleeding hemorrhoids. Hepatogastroenterology 1996; 43:1504.
  13. Lohsiriwat V. Hemorrhoids: from basic pathophysiology to clinical management. World J Gastroenterol 2012; 18:2009.
  14. Altomare DF, Rinaldi M, La Torre F, et al. Red hot chili pepper and hemorrhoids: the explosion of a myth: results of a prospective, randomized, placebo-controlled, crossover trial. Dis Colon Rectum 2006; 49:1018.
  15. Trompetto M, Clerico G, Cocorullo GF, et al. Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement. Tech Coloproctol 2015; 19:567.
  16. Wadworth AN, Faulds D. Hydroxyethylrutosides. A review of its pharmacology, and therapeutic efficacy in venous insufficiency and related disorders. Drugs 1992; 44:1013.
  17. Meyer OC. Safety and security of Daflon 500 mg in venous insufficiency and in hemorrhoidal disease. Angiology 1994; 45:579.
  18. Godeberge P. Daflon 500 mg in the treatment of hemorrhoidal disease: a demonstrated efficacy in comparison with placebo. Angiology 1994; 45:574.
  19. Cospite M. Double-blind, placebo-controlled evaluation of clinical activity and safety of Daflon 500 mg in the treatment of acute hemorrhoids. Angiology 1994; 45:566.
  20. Buckshee K, Takkar D, Aggarwal N. Micronized flavonoid therapy in internal hemorrhoids of pregnancy. Int J Gynaecol Obstet 1997; 57:145.
  21. Misra MC, Parshad R. Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal haemorrhoids. Br J Surg 2000; 87:868.
  22. Ho YH, Foo CL, Seow-Choen F, Goh HS. Prospective randomized controlled trial of a micronized flavonidic fraction to reduce bleeding after haemorrhoidectomy. Br J Surg 1995; 82:1034.
  23. Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, et al. Meta-analysis of flavonoids for the treatment of haemorrhoids. Br J Surg 2006; 93:909.
  24. Perera N, Liolitsa D, Iype S, et al. Phlebotonics for haemorrhoids. Cochrane Database Syst Rev 2012; :CD004322.
  25. Gorfine SR. Treatment of benign anal disease with topical nitroglycerin. Dis Colon Rectum 1995; 38:453.
  26. Lund JN, Scholefield JH. A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet 1997; 349:11.
  27. Tjandra JJ, Tan JJ, Lim JF, et al. Rectogesic (glyceryl trinitrate 0.2%) ointment relieves symptoms of haemorrhoids associated with high resting anal canal pressures. Colorectal Dis 2007; 9:457.
  28. van den Berg M, Stroeken HJ, Hoofwijk AG. [Favorable results of conservative treatment with isosorbide dinitrate in 25 patients with fourth-degree hemorrhoids: a pilot study]. Ned Tijdschr Geneeskd 2003; 147:971.
  29. Perrotti P, Antropoli C, Molino D, et al. Conservative treatment of acute thrombosed external hemorrhoids with topical nifedipine. Dis Colon Rectum 2001; 44:405.
  30. Patti R, Arcara M, Bonventre S, et al. Randomized clinical trial of botulinum toxin injection for pain relief in patients with thrombosed external haemorrhoids. Br J Surg 2008; 95:1339.
  31. Shafik A. Role of warm-water bath in anorectal conditions. The "thermosphincteric reflex". J Clin Gastroenterol 1993; 16:304.
  32. Dodi G, Bogoni F, Infantino A, et al. Hot or cold in anal pain? A study of the changes in internal anal sphincter pressure profiles. Dis Colon Rectum 1986; 29:248.
  33. Shanmugam V, Thaha MA, Rabindranath KS, et al. Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids. Cochrane Database Syst Rev 2005; :CD005034.
  34. Linares Santiago E, Gómez Parra M, Mendoza Olivares FJ, et al. Effectiveness of hemorrhoidal treatment by rubber band ligation and infrared photocoagulation. Rev Esp Enferm Dig 2001; 93:238.
  35. Poen AC, Felt-Bersma RJ, Cuesta MA, et al. A randomized controlled trial of rubber band ligation versus infra-red coagulation in the treatment of internal haemorrhoids. Eur J Gastroenterol Hepatol 2000; 12:535.
  36. Marques CF, Nahas SC, Nahas CS, et al. Early results of the treatment of internal hemorrhoid disease by infrared coagulation and elastic banding: a prospective randomized cross-over trial. Tech Coloproctol 2006; 10:312.
  37. Chand M, Nash GF, Dabbas N. The management of haemorrhoids. Br J Hosp Med (Lond) 2008; 69:35.
  38. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatment modalities. A meta-analysis. Dis Colon Rectum 1995; 38:687.
  39. MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments: a meta-analysis. Can J Surg 1997; 40:14.
  40. Nelson RS, Ewing BM, Ternent C, et al. Risk of late bleeding following hemorrhoidal banding in patients on antithrombotic prophylaxis. Am J Surg 2008; 196:994.
  41. Buchmann P, Seefeld U. Rubber band ligation for piles can be disastrous in HIV-positive patients. Int J Colorectal Dis 1989; 4:57.
  42. Khubchandani IT. A randomized comparison of single and multiple rubber band ligations. Dis Colon Rectum 1983; 26:705.
  43. Berkelhammer C, Moosvi SB. Retroflexed endoscopic band ligation of bleeding internal hemorrhoids. Gastrointest Endosc 2002; 55:532.
  44. Su MY, Chiu CT, Wu CS, et al. Endoscopic hemorrhoidal ligation of symptomatic internal hemorrhoids. Gastrointest Endosc 2003; 58:871.
  45. Fukuda A, Kajiyama T, Arakawa H, et al. Retroflexed endoscopic multiple band ligation of symptomatic internal hemorrhoids. Gastrointest Endosc 2004; 59:380.
  46. Wehrmann T, Riphaus A, Feinstein J, Stergiou N. Hemorrhoidal elastic band ligation with flexible videoendoscopes: a prospective, randomized comparison with the conventional technique that uses rigid proctoscopes. Gastrointest Endosc 2004; 60:191.
  47. Dickey W, Garrett D. Hemorrhoid banding using videoendoscopic anoscopy and a single-handed ligator: an effective, inexpensive alternative to endoscopic band ligation. Am J Gastroenterol 2000; 95:1714.
  48. Ramzisham AR, Sagap I, Nadeson S, et al. Prospective randomized clinical trial on suction elastic band ligator versus forceps ligator in the treatment of haemorrhoids. Asian J Surg 2005; 28:241.
  49. Suction vs forcep: band ligation for hemorrhoid treatment a prospective, randomized study www.cookmedical.com/esc/educationArticle.do?id=7408 (Accessed on October 05, 2011).
  50. Iyer VS, Shrier I, Gordon PH. Long-term outcome of rubber band ligation for symptomatic primary and recurrent internal hemorrhoids. Dis Colon Rectum 2004; 47:1364.
  51. Scarpa FJ, Hillis W, Sabetta JR. Pelvic cellulitis: a life-threatening complication of hemorrhoidal banding. Surgery 1988; 103:383.
  52. Wechter DG, Luna GK. An unusual complication of rubber band ligation of hemorrhoids. Dis Colon Rectum 1987; 30:137.
  53. Marshman D, Huber PJ Jr, Timmerman W, et al. Hemorrhoidal ligation. A review of efficacy. Dis Colon Rectum 1989; 32:369.
  54. Albuquerque A. Rubber band ligation of hemorrhoids: A guide for complications. World J Gastrointest Surg 2016; 8:614.
  55. Khoury GA, Lake SP, Lewis MC, Lewis AA. A randomized trial to compare single with multiple phenol injection treatment for haemorrhoids. Br J Surg 1985; 72:741.
  56. Mann CV, Motson R, Clifton M. The immediate response to injection therapy for first-degree haemorrhoids. J R Soc Med 1988; 81:146.
  57. Scaglia M, Delaini GG, Destefano I, Hultén L. Injection treatment of hemorrhoids in patients with acquired immunodeficiency syndrome. Dis Colon Rectum 2001; 44:401.
  58. Kaman L, Aggarwal S, Kumar R, et al. Necrotizing fascitis after injection sclerotherapy for hemorrhoids: report of a case. Dis Colon Rectum 1999; 42:419.
  59. Barwell J, Watkins RM, Lloyd-Davies E, Wilkins DC. Life-threatening retroperitoneal sepsis after hemorrhoid injection sclerotherapy: report of a case. Dis Colon Rectum 1999; 42:421.
  60. Schulte T, Fändrich F, Kahlke V. Life-threatening rectal necrosis after injection sclerotherapy for haemorrhoids. Int J Colorectal Dis 2008; 23:725.
  61. Iwagaki H, Higuchi Y, Fuchimoto S, Orita K. The laser treatment of hemorrhoids: results of a study on 1816 patients. Jpn J Surg 1989; 19:658.
  62. O'Connor, JJ. Infrared coagulation of hemorrhoids. Practical Gastroenterology 1986; 10:8.
  63. https://www.nice.org.uk/guidance/ipg525 (Accessed on May 22, 2017).
  64. Kantsevoy SV, Bitner M. Nonsurgical treatment of actively bleeding internal hemorrhoids with a novel endoscopic device (with video). Gastrointest Endosc 2013; 78:649.
  65. Crawshaw BP, Russ AJ, Ermlich BO, et al. Prospective Case Series of a Novel Minimally Invasive Bipolar Coagulation System in the Treatment of Grade I and II Internal Hemorrhoids. Surg Innov 2016; 23:581.
  66. Hodgson WJ, Morgan J. Ambulatory hemorrhoidectomy with CO2 laser. Dis Colon Rectum 1995; 38:1265.
  67. Senagore A, Mazier WP, Luchtefeld MA, et al. Treatment of advanced hemorrhoidal disease: a prospective, randomized comparison of cold scalpel vs. contact Nd:YAG laser. Dis Colon Rectum 1993; 36:1042.
  68. Leff EI. Hemorrhoidectomy--laser vs. nonlaser: outpatient surgical experience. Dis Colon Rectum 1992; 35:743.
  69. Gill JR, Morrow JS, West AB. Fatal hemorrhage following laser hemorrhoidectomy. J Clin Gastroenterol 1994; 19:343.
  70. Buls JG, Goldberg SM. Modern management of hemorrhoids. Surg Clin North Am 1978; 58:469.
  71. McCloud JM, Jameson JS, Scott AN. Life-threatening sepsis following treatment for haemorrhoids: a systematic review. Colorectal Dis 2006; 8:748.
  72. Abramowitz L, Batallan A. [Epidemiology of anal lesions (fissure and thrombosed external hemorroid) during pregnancy and post-partum]. Gynecol Obstet Fertil 2003; 31:546.
  73. Morandi E, Merlini D, Salvaggio A, et al. Prospective study of healing time after hemorrhoidectomy: influence of HIV infection, acquired immunodeficiency syndrome, and anal wound infection. Dis Colon Rectum 1999; 42:1140.
  74. D'Ugo S, Franceschilli L, Cadeddu F, et al. Medical and surgical treatment of haemorrhoids and anal fissure in Crohn's disease: a critical appraisal. BMC Gastroenterol 2013; 13:47.