Home and office treatment of symptomatic

Home and office treatment of symptomatic

Bleday R, Breen E. UpToDate 2022; [cited 10 March 2022]; Available from: www.uptodate.com.

NOTE: Passing the test multiple times will not lead to a higher grade or more CPD points.


  • Haemorrhoids are collections of submucosal, fibrovasular, arteriovenous sinusoids that are part of the normalanorectum1
  • Symptoms include painless rectal bleeding during defaecation with or without prolapse (most common), anal pruritis or pain, and a lump at the anal verge from thrombosis or strangulation1
  • Most patients with low-grade internal haemorrhoids will experience relief with home-based conservative treatment or office-based procedures1
  • Surgery is indicated for low-grade haemorrhoids that are refractory to conservative treatment, high-grade haemorrhoids and complicated haemorrhoids1

Classification of haemorrhoids

  • Haemorrhoids can be internal, external or mixed, depending on their relationship to the dentate line1
  • Internal haemorrhoids originate from above the dentate line and are less sensitive to pain due to visceral innervation-amenable to office-based procedures with minimal or no anaesthesia1
  • External haemorrhoids originate from below the dentate line and are sensitive to pain due to somatic innervation– anaesthesia is necessary if treatedsurgically1
  • Mixed internal and external haemorrhoids straddle the dentate line and are treatedas external haemorrhoids1
  • Internal haemorrhoids are further subclassified into 4 grades depending on the degree of prolapse:1

Conservative treatment for all patients

  • Most patients with new-onset symptomatic haemorrhoids can be treated conservatively for as long as needed with dietary/lifestyle modification, and topical or oral medications to relieve symptoms1
Treatment approach by symptoms
Irritation or pruritis1
  • Analgesic creams, hydrocortisone suppositories, warm sitz baths
  • Dietary modification and external creams
  • Office-based procedures or surgery if bleeding persists
  • Conservative treatment is usually sufficient as clot usually resorbs and pain lessens within a few days
  • As grade worsens there is a greater benefit of office-based procedures or surgery

Dietary and lifestyle modification

Dietary and lifestyle modification
  • Increased fibre intake improves symptoms of bleeding, mild prolapse, irritation and pruritis1
  • Patients should ingest 20-30 g of insoluble fibre per day either through diet or supplements, and increase water intake to 1.5 to 2 litres a day1
  • Patients should be advised to refrain from straining or lingering on the toilet, to exercise, avoid medications that cause constipation or diarrhoea and to limit their intake of fatty foods and alcohol1

Medications for symptomatic relief

  • Hydrocortisone-lidocaine combinations are effective for relieving acute pain and topical steroids may relieve associated pruritis and shrink the haemorrhoids1
  • Venoactive agents or phlebotonics improve venous tone and may reduce bleeding, as well as other symptoms such as pruritis1
  • Antispasmodic agents, e.g., nitroglycerin, reduce anal sphincter spasm and associated pain1
  • Warm sitz baths 2-3 times a day reduce inflammation and oedema and relax anal sphincter tone1

Reasons to refer to a specialist

  • Symptomatic low-grade (I or II) internal haemorrhoids refractory to 6-8 weeks of medical treatment.1
  • Symptomatic high-grade (III or IV) internal haemorrhoids.1
  • Thrombosed haemorrhoids, with the exception of subacute (older than three days) thrombosed external haemorrhoids, which can be managed expectantly with resolution of symptoms expected in 7 to 10 days.1
  • Patients ≥ 40 years old with rectal bleeding should be referred for colonoscopy.1
  • Patients with haemorrhoids and one of the following conditions should be referred for colonoscopyregardless of age: anaemia, bleeding, concomitant change in bowel patterns, personal history of colorectalpolyps, family history of inflammatory bowel disease or colorectal cancer in a first-degree relative, or othersuspected pathologic pelvic changes that could contribute to the patient’s symptoms.1
Office-based procedures for symptomatic haemorrhoids

Office-based procedures for symptomatic haemorrhoids

  • Recommended for patients with symptomatic grade I, II, or III internal haemorrhoids refractory to conservativetreatment.1
  • Common procedures include rubber band ligation, sclerotherapy, infrared coagulation of internal haemorrhoids, and excision of thrombosed external haemorrhoids.1
  • Rubber band ligation is preferred for healthy patients with grade I, II, or III internal haemorrhoids, whereas sclerotherapy is preferred for patients who are on anticoagulants, are immunocompromised or have portalhypertension.1
  • Acutely thrombosed external haemorrhoids can be excised if patient presents within the first 3 days of symptoms.1
  • Grade IV internal haemorrhoids require definitive surgical treatment.1


Reference: 1. Bleday R, Breen E. UpToDate 2022; [cited 10 March 2022]; Available from: www.uptodate.com.

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