subject: Medical Therapy For Hemorrhoids [print this page] Many hemorrhoidal symptoms resolve only when they are treated with dietary alterations, including increased fiber and the addition of fiber supplements. Psyllium seed significantly decreases bleeding and pain compared with placebo. The average American diet consists of 8-15 grams of fiber per day. A high-fiber diet includes more than 25 grams of fiber per day. Psyllium seed and methylcellulose are the most commonly used supplements.
Antidiarrheal agents are sometimes required in patients with symptoms and loose stools. Toilet retraining involves reminding patients that the lavatory is not the library. Patients should sit on the toilet only long enough to evacuate the lower intestines. Persistent straining or prolonged sitting can lead to engorged hemorrhoids.
Stool softeners play a limited role in the treatment of routine hemorrhoidal symptoms. Oral fiber intake and fiber supplements almost always cure constipation and straining. Remember that hemorrhoidal symptoms are due to prolapse, thrombosis, and vascular bleeding; therefore, creams and salves have a small role in treating hemorrhoidal complaints.
Suppositories, except for providing lubrication, also have a small role in the treatment of hemorrhoidal symptoms. Topical hydrocortisone can sometimes ease internal hemorrhoidal bleeding. Some doctors rarely recommend typical medications (eg, suppository, cream, enema, foam) in the treatment of hemorrhoids. Submucosal veins do not get smaller with anti-inflammatory medications.
Bathing in tubs with warm water universally eases painful perianal conditions. Relaxation of the sphincter mechanism and spasm is probably the etiology. Ice can relieve the pain of acute thrombosis. Sitz baths do have a role in the treatment of older or immobile patients who cannot routinely get in and out of a bathtub.
Many patients see improvement or complete resolution of their symptoms with the above conservative measures. Aggressive therapy is reserved for patients who have persistent symptoms after 1 month of conservative therapy. Treatment is directed solely at symptoms and not at the appearance of the hemorrhoids.
Pregnancy is associated with many anorectal complaints. Treatment is directed at symptoms. Nonoperative treatment or office thrombectomy usually relieves complaints. Operative hemorrhoidectomy is safe in pregnant women. HIV and anal disease often occur together. Again, conservative therapy is suggested, especially if immunosuppression is evident.
Numerous methods to destroy internal hemorrhoids are available; they include rubber band ligation, sclerotherapy injection, infrared photocoagulation, laser ablation, carbon dioxide freezing, Lord dilatation, stapled hemorrhoidectomy, and surgical resection. All of these methods are considered nonoperative treatments and should be the first-line treatment of all first- and second-degree internal hemorrhoids that do not respond to conservative therapy.
With experience, many third-degree and some fourth-degree internal hemorrhoids can be treated nonoperatively. All nonoperative treatments have approximately similar efficiency when administered by an experienced clinician. The adverse effects of these treatments have a direct relationship to whether patients relay persistent or recurrent complaints to the clinician or return for further treatment.
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