Other phlebotonics (the botanicals ginkgo biloba, troxerutin, and calcium dobesilate), when compared with placebo19,20 or diosmin,21 have shown similar effects (SOR: B). No studies thus far have evaluated the role of phlebotonics in thrombosis of external hemorrhoids.
Anti-inflammatories and analgesics. Most episodes of acute thrombosed external hemorrhoids improve spontaneously and therefore can be treated with symptomatic measures, including anti-inflammatory agents, analgesics, and stool softeners. Anti-inflammatories and analgesics can be effective during episodes of external and internal thromboses3 (SOR: D). Several clinical trials have reported benefits of fiber in relieving pain, bleeding, and prolapse
In a small randomized clinical trial, the addition of topical nifedipine (0.3%) to a lidocaine ointment (1.5%) was more effective than lidocaine alone in reducing pain and shortening resolution time.22
Surgical treatment
All office (nonoperative) and surgical procedures fix the sliding hemorrhoidal tissue back onto the muscle wall. The fixation takes place by directly promoting tissue fibrosis (eg, sclerotherapy or infrared coagulation) or by tissue destruction with subsequent fibrosis (eg, hemorrhoidectomy).
Office procedures. The most commonly used methods are rubber band ligation and infrared coagulation. Other methods include bipolar electrocoagulation, low-voltage direct current, sclerotherapy, laser therapy, and cryosurgery.
Two meta-analyses compared these nonoperative methods and concluded that rubber band ligation and infrared coagulation are the most effective. The first meta-analysis reported that ligation was more effective because it required fewer additional treatments for symptomatic recurrence than did coagulation (number needed to treat [NNT]=9) and sclerotherapy (NNT=6.9).23 However, ligation produced more complications than did coagulation (pain: number needed to harm=6) (SOR: A).
The second, more recent meta-analysis found ligation to have similar beneficial effect and a similar complication rate,24 although it was more painful. It appeared to be the therapy of choice for grades I to III (SOR: A). No difference was found between sclerotherapy and infrared coagulation for any outcome measure, but the authors of these meta-analyses commented that the overall quality of the studies was not high and their conclusions were therefore limited. One subsequent randomized clinical trial confirmed the advantages of rubber band ligation.25
In the event of a thrombosed hemorrhoid, whether to remove the clot promptly or wait for spontaneous resolution is controversial. We found no studies comparing these approaches. Excision should be performed when local measures fail, the thrombosis is painful, and there is no local edema (SOR: D).3
In the treatment of perianal thrombosis, one clinical trial found excision more effective than topically applied 0.2% glyceryl trinitrate or incision in reducing pain and the number of recurrences at 1 year (SOR: A).26 Residual hemorrhoidal tissue following an episode of acute thrombosis of external hemorrhoids also may cause symptoms, especially pruritus. These external anal tags can make it difficult to clean the anus and can be excised if symptoms warrant.
Surgery. Surgical treatment, though more invasive and expensive, is the most effective and definitive course for symptomatic hemorrhoids. The aim is to decrease blood flow to the anorectal ring and excise redundant hemorrhoidal tissue.
There are several techniques. In the United States, the Ferguson (closed) hemorrhoidectomy is preferred. The one used most commonly in Europe is the Milligan-Morgan technique (open). Both techniques have been shown to be similarly effective, although there is debate over healing time.27-30 Only a competently performed technique will produce satisfying results.
In their meta-analysis, MacRae and McLeod found that hemorrhoidectomy is more effective than all other treatment modalities, though complications such as pain and costs were greater (SOR: A).24
A new surgical procedure, the stapled hemorrhoidectomy, has been introduced as an alternative to the standard hemorrhoidectomy. Several randomized clinical trials have shown the procedure to be as effective, cause less pain, and require less time off from work compared with standard techniques (SOR: A).31-36 However, it is more expensive and requires advanced surgical skills. More long-term data are also needed.37
Anal stretch, or manual anal dilatation, has been reported to be effective in the treatment of hemorrhoids, but a high rate of incontinence after the procedure has led to abandonment of this technique.38,39 Antibiotic prophylaxis in colorectal surgery is highly recommended and has been shown to reduce infection and mortality (SOR: A).40
Surgery vs office procedures
Several clinical practice guidelines3,38 and meta-analyses23,24 have recommended office procedures for hemorrhoids of grades I through III. Although there is some discrepancy about the procedure of choice, rubber band ligation appears to be the most effective technique.
An evidence-based clinical practice guideline3 has recommended coagulation techniques for bleeding nonprolapsed hemorrhoids or those with a low grade of prolapse (grades I and II), and reserving rubber band ligation for hemorrhoids more severely prolapsed (grade III). The basis for this recommendation is that flat bleeding hemorrhoids may not provide enough tissue to grasp.