Treatment of hemorrhoids
- Ronald Bleday, MD
Ronald Bleday, MD
- Associate Professor of Surgery
- Harvard Medical School
- Elizabeth Breen, MD
Elizabeth Breen, MD
- Assistant Professor of Surgery
- Harvard Medical School
Hemorrhoids are normal vascular structures in the anal canal. However, they are often the source of a variety of problems. The cardinal features of hemorrhoidal disease include anal pruritus, prolapse, bleeding, and pain due to thrombosis. Although these symptoms may strongly suggest the diagnosis, confirmation by flexible sigmoidoscopy, anoscopy, or colonoscopy should be performed in patients who present with bleeding. Colonoscopy is generally recommended in older patients to exclude more serious underlying disease (eg, malignancy). (See "Hemorrhoids: Clinical manifestations and diagnosis".)
A variety of over-the-counter preparations is available for the treatment of hemorrhoids, and patients often seek medical attention only after these modalities have failed. Thus, patients presenting to their physicians probably represent a group with relatively severe disease.
Several options are available for the treatment of symptomatic hemorrhoids, and most patients will have relief with conservative or office-based treatment approaches. These are reviewed below. Surgery is indicated for those whose symptoms are refractory to conservative measures or office-based treatment approaches, those who have developed complications, and as a primary treatment for patients with certain problems. (See 'Referral for surgery' below.)
Surgical procedures used to treat hemorrhoids are reviewed separately. (See "Surgical treatment of hemorrhoidal disease".)
CLASSIFICATION AND TREATMENT APPROACH
Hemorrhoids are classified relative to their relationship to the dentate line as internal (above) or external (below) (figure 1). Internal hemorrhoids are graded relative to their severity (ie, degree to which they prolapse from the anal canal). (See "Hemorrhoids: Clinical manifestations and diagnosis", section on 'Classification'.)
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- CLASSIFICATION AND TREATMENT APPROACH
- Irritation or pruritus
- Bleeding hemorrhoids
- Thrombosed hemorrhoids
- Prolapsed internal hemorrhoids
- CONSERVATIVE TREATMENTS
- Topical antiinflammatory agents
- Venoactive agents
- Antispasmodic agents
- Sitz baths
- OFFICE-BASED PROCEDURES FOR INTERNAL HEMORRHOIDS
- Choice of office-based technique
- - Rubber band ligation
- - Sclerotherapy
- - Infrared coagulation
- - Others
- POSTPROCEDURE CARE AND FOLLOW-UP
- COMPLICATIONS OF TREATMENT
- REFERRAL FOR SURGERY
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS