Treatment Options for Relief From Hemorrhoids

Learn more about different treatment options for hemorrhoids.

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About 5 percent of all people have hemorrhoids, including half of all adults aged 50 or more. Furthermore, an estimated 1 million people in the Western world have hemorrhoids.

What Are Hemorrhoids?

Three hemorrhoidal cushions composed of smooth muscle, connective tissue, blood vessels and so forth surround and support the terminal connections between the rectal arteries in the anal canal. In addition to support, these cushions help maintain fecal continence by engorging with blood.

These cushions also provide sensory feedback which helps the body discriminate between solid, liquid and gas. Finally, these cushions help us decide when to defecate.

Sometimes the hemorrhoidal cushions become swollen with blood and thus become painful, inflamed and uncomfortable. Such "hemorrhoids" result from prolonged straining during defecation (constipation), diarrhea, pregnancy, prolonged sitting and so forth. Typically, people who develop hemorrhoids have a family history of the disease.

There are 2 types of hemorrhoids: internal and external. These 2 types of hemorrhoids lie on either side of the pectinate (dentate) line which divides the upper two-thirds of the anal canal from the bottom one-third. Internal hemorrhoids have no innervation and are painless; whereas, you can feel external hemorrhoids.

Diagnosing Hemorrhoids

A diagnosis of hemorrhoids is based on history and physical exam.

Here are some clinical features of hemorrhoids:

  • blood in the toilet bowl or on tissue (the blood is typically bright red because blood vessels in the anal canal are highly vascular)
  • itchiness (pruritis)
  • pain (usually described as a dull ache but can be more severe with thrombosis or clotting)
  • protrusion or mass (with more advanced stages of hemorrhoids, these masses become prolapsed and irreducible--"can't be pushed back in"--and can possibly strangulate, a medical emergency)
  • extra skin or tissue

More rarely, what appears to be a hemorrhoid may actually be something more serious which is one good reason to have even a relatively "mild" case of hemorrhoids examined by your physician. Here are some other causes of anal mass and bleeding:

  • anal fissure or tear
  • abscess
  • inflammatory bowel disease (Crohn's disease or ulcerative colitis)
  • rectal prolapse (where the rectum protrudes into the anal canal) usually secondary to pelvic-floor disease (incontinence) in women
  • condyloma acuminata (genital warts)

Treatment for Hemorrhoids

If possible, you'll want to avoid surgery for hemorrhoids. Lots of people who have surgery for hemorrhoids complain of pain and dissatisfaction after the procedure. For instance, results from one study suggest that 59 percent of people who underwent rubber-band ligation later claimed they wouldn't have the surgery again.

Here are some nonsurgical treatment options for hemorrhoids:

  • lifestyle modification such as increased consumption of fiber and fiber supplements can help with bleeding, itching and pain
  • steroid creams or suppositories
  • topical nifedipine and lidocaine (shown to help in a small randomized-control trial)

Of note, sitz baths have proven ineffective when treating hemorrhoids.

With respect to surgery, internal hemorrhoids are treated differently from external hemorrhoids. Depending on stage, severity and presentation, internal hemorrhoids can be treated using sclerotherapy, rubber-band ligation and infrared photocoagulation. Please note that because of bleeding risk, for people on anticoagulation, rubber-band ligation is not usually recommended. Sometimes external hemorrhoids can be removed or excised in an outpatient or emergency room setting.

When hemorrhoids are higher stage or more severe, a surgeon may need to perform open surgery in an operating room. The surgeon may either remove (excise) the hemorrhoids or staple them (hemorrhoidopexy). Results comparing excision with stapling are mixed with a recent Cochrane review suggesting that stapling resulted in lower recurrence rates but higher risk of prolapse.

After surgery, patients are typically prescribed pain medications. Metronidazole can also be prescribed as antibiotic prophylaxis.

Bottom Line

If you or someone you love is suffering from what you assume to be an irritating case hemorrhoids, please make an appointment to see your primary care physician. Although most cases of hemorrhoids resolve on their own, other more serious and rare conditions (like cancer), can similarly present. On a final note, although surgery is last line treatment for hemorrhoids, and most people find surgery for hemorrhoids very uncomfortable, surgery is remarkably effective with less than 10 percent of cases recurring.


Usatine RP, Smith MA, Chumley HS, Mayeaux EJ, Jr.. Chapter 66. Hemorrhoids. In: Usatine RP, Smith MA, Chumley HS, Mayeaux EJ, Jr.. eds. The Color Atlas of Family Medicine, 2e. New York, NY: McGraw-Hill; 2013.

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