Management of Hemorrhoids: Guidelines From the ASCRS

Hemorrhoids are perianal vascular structures defined as external or internal by their relationship to the dentate line, although they often coexist and communicate with each other. Symptoms due to hemorrhoids are common in the industrialized world, although other sources of perianal symptoms can be misinterpreted as hemorrhoidal. The American Society of Colon and Rectal Surgeons (ASCRS) has published guidelines on the diagnosis and management of hemorrhoids.

Hemorrhoids are typically diagnosed clinically from suggestive symptoms and physical examination findings. External hemorrhoids are an external protrusion that can be difficult to clean, with irritation caused by prolonged contact with fecal material. Thrombosed external hemorrhoids present as painful, nonreducible protrusions at the anal verge. Internal hemorrhoids most often manifest with painless bleeding with bowel movements, occasionally with intermittent tissue protrusion.

Because constipation is commonly associated with hemorrhoids, the frequency, consistency, and ease of bowel movements should be reviewed. Digital rectal examination is recommended to rule out other anorectal pathology and evaluate sphincter tone. Anoscopy can be considered to exclude other pathology.

Although most patients with symptoms suggestive of hemorrhoids do not have colon cancer, bleeding due to colon cancer is often misattributed to hemorrhoids. Colonoscopy should be considered for patients with no obvious source of bleeding or symptoms including abdominal pain, new or progressive constipation, and continued hematochezia despite successful treatment of hemorrhoids.

Diet and Behavioral Changes

Patients with hemorrhoids should be treated for underlying constipation. Increasing fiber and fluid intake is strongly recommended to improve hemorrhoid prolapse and bleeding. Based on a Cochrane review of approximately 380 patients, increasing fiber intake decreases persistent symptoms by 53% compared with usual care without fiber. Increased fiber intake also significantly reduces bleeding.

Patients should be advised to avoid straining and spending prolonged time on the commode.

Topical Treatments and Supplements

Topical over-the-counter hemorrhoid treatments (eg, hydrocortisone, phenylephrine, pramoxine) can be considered, which can significantly improve pain, pruritus, and swelling. Use of hydrocortisone and pramoxine is safe and effective in late pregnancy. Patients should be advised that prolonged use of topical treatments containing anesthetics, steroids, or antiseptics can cause allergic reactions and long-term sensitization.

Flavonoid-containing oral supplements can be suggested because they appear to be beneficial in reducing pruritus, bleeding, discharge, and leakage. Flavonoids are plant extracts that have been shown to improve overall symptoms compared with placebo. The mechanism is unknown, although they may work by strengthening blood vessel walls, increasing lymphatic drainage, and normalizing capillary permeability.

Rubber Band Ligation

Patients who continue to have symptoms should be referred for rubber band ligation. This is performed by surgeons or primary care physicians in-office. An elastic band is placed proximal to the dentate line to strangulate the hemorrhoidal column and affix the mucosa to submucosa to resolve mucosal prolapse.