Hemorrhoids: A range of treatments

Cleveland Clinic Journal of Medicine. 2019 September;86(9):612-620 | 10.3949/ccjm.86a.18079
September 3, 2019|Cleveland Clinic Journal of Medicine
Turgut Bora Cengiz, MD;Emre Gorgun, MD, FACS, FASCRS
Author and Disclosure Information

Turgut Bora Cengiz, MD
Department of General Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic

Emre Gorgun, MD, FACS, FASCRS
Department of Colorectal Surgery, Digestive Disease and Surgery Institute, Cleveland Clinic; Clinical Assistant Professor, Cleveland Clinic Lerner College of Medicine of Case Western Reserve University, Cleveland, OH

Address: Emre Gorgun, MD, FACS, FASCRS, Department of Colorectal Surgery, A30, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44195; gorgune@ccf.org

Release date: September 1, 2019
Expiration date: August 31, 2020
Estimated time of completion: 1 hour

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ABSTRACT

Hemorrhoids are a common reason for office visits. Each patient is unique, and with a range of treatments available, treatment can be individualized. This article reviews the diagnosis and decision-making process for individualized treatment.

KEY POINTS

  • Hemorrhoids account for more than 3.5 million office visits annually.
  • Most patients present with painless rectal bleeding, but this can also be a sign of colorectal cancer, which needs to be ruled out.
  • Fiber supplements along with dietary and lifestyle changes are recommended for all patients with hemorrhoids regardless of symptom severity.
  • Hemorrhoids are graded on a scale of I (least severe) through IV (most severe). Office-based treatments are effective for grades I, II, and some grade III hemorrhoids. Surgical excision is the standard for high-grade hemorrhoids.

CONSERVATIVE MEASURES

Conservative measures are aimed at softening the stool, relieving pain, and correcting bad toileting habits. In most cases, the primary precipitating factor is lifestyle, and unless patients change it, they are more likely to have recurrent symptoms in the long term.

No phone in the bathroom

People take their phones into the bathroom, and this habit is blamed for increasing the time on the toilet and leading to increased pressure on the anal region and straining during defecation. Some research points to a direct correlation between the time spent on the toilet and hemorrhoidal disease, although the exact cause-and-effect relationship with cell phone use has not been determined. In general, spending excessive time on the commode, including reading, should be discouraged.

Less time in the bathroom

Johannsson et al6 reported that patients with hemorrhoids spent more time on the toilet and had to strain harder and more often than controls in the community and hospital.

,

Garg and Singh7 and Garg8 use the mnemonic “TONE” for appropriate defecation habits:

  • Three minutes during defecation
  • Once-daily defecation
  • No straining and no cell phone use during defecation
  • Enough fiber.

More fiber

Fiber draws water into the lumen of the colon, increasing the water content of the stool. Recommended daily fiber intake is about 28 g for women and 38 g for men.9 This high level of intake is hard to achieve without supplements for someone who consumes a classic American diet with a lot of fast food.

Fiber supplements are strongly recommended in the American Society of Colon and Rectal Surgeons (ASCRS) practice guidelines3 based on a Cochrane review.10 In this meta-analysis, with fiber supplements, the relative risk of persisting or nonimproving symptoms was 0.53 (95% confidence interval [CI] 0.38–0.73) and the relative risk of bleeding was 0.50 (95% CI 028–0.89). Psyllium husk is an inexpensive bulk-forming fiber supplement; the optimal daily dosage is not known.

We recommend at least 28 g of daily fiber intake for women and 38 g for men, for which psyllium husk can be used to complement the diet.

Laxatives for some

Laxatives such as docusate are used to change the stool consistency when there is an organic bowel problem rather than a dietary issue. They can be used as a complementary treatment to enhance the effect of the fiber treatment.

Other measures

Topical anesthesia (eg, 5% lidocaine) is commonly used to treat pain from low-grade lesions, but no reliable data have been published. As most cases of hemorrhoids tend to progress over time, one should not expect long-term improvement with topical anesthesia. Nevertheless, it can be used as an ancillary treatment in select cases when short-term improvement is the main goal, and we recommend it based on our own experience.

Hygiene. Bidet use or cleaning the perianal area with water is recommended.

Phlebotonics contain a variety of ingredients including natural plant extracts such as flavonoids and synthetic products. Even though the exact mechanism of action is not known, phlebotonics are thought to increase venous and lymphatic drainage, normalize capillary permeability, and decrease inflammation in the hemorrhoidal cushions.4,11–13

In a Cochrane review of 24 randomized controlled trials, Perera et al14 found that phlebotonics improved the outcomes of:

  • Bleeding (odds ratio [OR] 0.21, number needed to treat [NNT] 4.8, P = .0002)
  • Pruritus (OR 0.23, NNT 9.1, P = .02)
  • Discharge or leakage (OR 0.12, NNT 5, P = .0008)
  • Overall symptoms (OR 15.99, NNT 2.7, P < .00001). Overall symptoms were also improved in the subgroup of pregnant patients.

Although phlebotonics give better results than placebo in the short-term management of hemorrhoids, there is a paucity of long-term data. Thus, the ASCRS clinical practice guidelines gives the regular use of these agents only a weak recommendation.3

Flavonoids (diosmin, hesperidin, rutoside), in a meta-analysis vs placebo in 1,514 patients, showed a beneficial response in terms of bleeding (relative risk [RR] 0.33), pruritus (relative risk [RR] 0.65), and recurrences (RR 0.53).15

Although Preparation H is commonly used as an over-the-counter medication, there are no good data on it, and it is not considered a phlebotonic.