Hemorrhoid Management

Aka: Hemorrhoid Management

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II. Prevention

  1. Avoid Constipation (mainstay of therapy)
    1. Goal is soft bulky stool that is easily passed without straining
    2. High bulk diet (soluble Dietary Fiber) 30 grams per day or fiber supplement (e.g. Citrucel or Metamucil)
      1. Decreases overall symptoms as well as decreases Hemorrhoidal bleeding by 50%
      2. Alonso-Coello (2005) Cochrane Database Syst Rev (4):CD004649 [PubMed]
    3. Increased volume of fluids 64 ounces non-caffeinated fluid per day
    4. Stool Softener (e.g. Polyethylene Glycol) if needed
    5. Avoid Irritant Laxatives
  2. Avoid increased anorectal pressure
    1. Do not strain at stool
    2. Do not sit on toilet for prolonged periods
      1. Do not read on toilet
  3. Minimize anorectal local inflammation
    1. Practice good hygiene
      1. Baby wipes without Alcohol
    2. Avoid topical irritant or allergens
      1. Use only hypoallergenic soaps
      2. Use only white toilet tissue

III. Medications: Topical agents (typically found in combination agents)

  1. Region cleaning and and to decrease burning
    1. Witch hazel Tucks (astringent)
  2. Decrease bleeding, swelling, itching or burning
    1. Phenylephrine (Decongestant, e.g. preparation H)
    2. May be used internally, externally
  3. Skin protectants
    1. Zinc Oxide
    2. Petrolatum (e.g. vaseline)
  4. Topical Anesthetics
    1. Topical Lidocaine, dibucaine or pramoxine or other agents
    2. Transient relief only
    3. Use only externally (no significant benefit inside the Rectum, and may cause irritation)
  5. Antiinflammatory to decrease significant itching or pain
    1. Low potency Topical Corticosteroids (e.g. Hydrocortisone 1%)
    2. Consider if other agents are ineffective, and avoid use more than 7 days
  6. Efficacy
    1. Evidence is lacking for any specific topicals
    2. No evidence for benefit of more expensive prescription items (e.g. proctofoam, anusol HC) over OTC agents
  7. References
    1. (2024) Presc Lett 31(9): 50

IV. Medications: Topical Agents in Pregnancy

  1. Topical external medications considered safe in pregnancy
    1. Witch Hazel (Tucks)
    2. Petrolatum (topical protectant)
    3. Hydrocortisone 1%
      1. Thin layer twice daily for up to 10 consecutive days is considered safe
    4. Lidocaine
      1. Considered safe after first trimester
    5. Pramoxine (Topical Anesthetic, Proctofoam HC)
      1. Considered safe in third trimester
      2. Ebrahimi (2011) J Obstet Gynaecol Can 33(2): 153-8 [PubMed]
  2. Precautions
    1. Avoid internal use or regular use of topical agents
    2. Avoid Phenylephrine containing products (e.g. preparation H)
      1. May decrease uterine perfusion
  3. References
    1. (2019) Presc Lett 26(8):45

V. Management

  1. General
    1. See individual preparations listed above
    2. Most topical Hemorrhoidal agents are combinations of these preparations
    3. No evidence for prescription topicals (anusol-HC) over OTC Medications (Preparation-H)
  2. Pain (External Hemorrhoids, esp. Thrombosed Hemorrhoids)
    1. Manage Thrombosed Hemorrhoid if present
    2. Topical astringent wipes (e.g. Witch Hazel Tucks)
      1. Sooths burning pain and clean the area
    3. Hydrocortisone (no proven benefit if no inflammation; avoid prolonged use)
      1. Preparation-H (contains Phenylephrine)
        1. Anusol HC
      2. ProctoFoam HC
    4. Analgesics
    5. Topical Anesthetics (e.g. 5% Lidocaine ointment)
      1. Short-term use externally only
      2. Best used prior to having a Bowel Movement
      3. As an alternative, small amount of shaving cream may be applied to the anus prior to Bowel Movement
        1. Not evidence-based, but readily available, and unlikely to cause harm
        2. Fisher and Swaminathan (2023) MacGyver Moves: Anal Care, EM:RAP
    6. Cold pack applied to anal area
    7. Warm sitz bath in tub for 20-30 minutes twice daily
      1. No evidence of benefit, but may be soothing and is without risk
      2. A plastic bed pan with warm water can be used by patients when not at home (e.g. at work, in bathroom stall)
  3. Other measures
    1. Oral Bioflavinoid supplements or Phlebotonics (e.g. Hidrosmin, hesperidin)
      1. Some studies suggest decreased bleeding, Pruritus or fecal leakage
      2. Not FDA approved
      3. Perera (2012) Cochrane Database Syst Rev (8):CD004322 +PMID: 22895941 [PubMed]

VI. References

  1. Pickard in Dornbrand (1992) Ambulatory Care, p. 225-6
  2. Goroll (2000) Primary Care, p. 430-1
  3. Schrock in Feldman (1998) Sleisenger GI, p. 1964-7
  4. Hulme-Moir (2001) Gastroenterol Clin North Am 30:183-97 [PubMed]
  5. Hussain (1999) Prim Care 26(1):35-51 [PubMed]
  6. Mott (2018) Am Fam Physician 97(3): 172-9 [PubMed]

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