Rectum

Hemorrhoid Management

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Hemorrhoid Management

  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. Colace)
  5. Avoid Irritant Laxatives
  • Prevention
  • 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
  • Prevention
  • 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
  • Preparations
  • Topical agents (typically found in combination agents)
  1. Decrease bleeding and swelling
    1. Witch hazel Tucks (astringent)
    2. Phenylephrine (Decongestant)
  2. Skin protectants
    1. Zinc Oxide
  3. Antiinflammatory
    1. Topical Corticosteroids
  4. Topical anesthetics
    1. Topical Lidocaine or other agents
  • Preparations
  • Topical Agents in Pregnancy
  1. Topical external medications considered safe in pregnancy
    1. Witch Hazel (Tucks)
    2. Petrolatum (topical protectant)
    3. Pramoxine (topical anesthetic)
    4. Hydrocortisone 1%
  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
  • 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. Topical astringent wipes (e.g. Witch Hazel Tucks)
      1. Sooths burning pain and clean the area
    2. Hydrocortisone (no proven benefit if no inflammation; avoid prolonged use)
      1. Preparation-H (contains Phenylephrine)
        1. Anusol HC
      2. ProctoFoam HC
    3. Analgesics
    4. Topical anesthetics (e.g. Lidocaine ointment)
      1. Shortterm use externally only
    5. Cold pack applied to anal area
    6. Hot sitz bath in tub for 20-30 minutes twice daily
      1. No evidence of benefit
  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]
  • 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]