EVIDENCE-BASED ANSWER
Excision is the most effective treatment for thrombosed external hemorrhoids (strength of recommendation [SOR]: B, retrospective studies). For prolapsed internal hemorrhoids, the best definitive treatment is traditional hemorrhoidectomy (SOR: A, systematic reviews). Of nonoperative techniques, rubber band ligation produces the lowest rate of recurrence (SOR: A, systematic reviews).
Evidence summary
External hemorrhoids originate below the dentate line and become acutely painful with thrombosis. They can cause perianal pruritus and excoriation because of interference with perianal hygiene. Internal hemorrhoids become symptomatic when they bleed or prolapse (TABLE).
TABLE
Classification of symptomatic internal hemorrhoids
| GRADE | DESCRIPTION |
|---|---|
| I | Hemorrhoids do not protrude, but may bleed |
| II | Hemorrhoids protrude with defecation, but reduce spontaneously |
| III | Hemorrhoids protrude and must be reduced by hand |
| IV | Hemorrhoids are permanently prolapsed |
| Source: Madoff RD, et al. Gastroenterology. 2004.10 | |
For thrombosed external hemorrhoids, surgery works best
Few studies have evaluated the best treatment for thrombosed external hemorrhoids. A retrospective study of 231 patients treated conservatively or surgically found that the 48.5% of patients treated surgically had a lower recurrence rate than the conservative group (number needed to treat [NNT]=2 for recurrence at mean follow-up of 7.6 months) and earlier resolution of symptoms (average 3.9 days compared with 24 days for conservative treatment).1
Another retrospective analysis of 340 patients who underwent outpatient excision of thrombosed external hemorrhoids under local anesthesia reported a low recurrence rate of 6.5% at a mean follow-up of 17.3 months.2
A prospective, randomized controlled trial (RCT) of 98 patients treated nonsurgically found improved pain relief with a combination of topical nifedipine 0.3% and lidocaine 1.5% compared with lidocaine alone. The NNT for complete pain relief at 7 days was 3.3
Conventional hemorrhoidectomy beats stapling
Many studies have evaluated the best treatment for prolapsed hemorrhoids. A Cochrane systematic review of 12 RCTs that compared conventional hemorrhoidectomy with stapled hemorrhoidectomy in patients with grades I to III hemorrhoids found a lower rate of recurrence (follow-up ranged from 6 to 39 months) in patients who had conventional hemorrhoidectomy (NNT=14).4 Conventional hemorrhoidectomy showed a nonsignificant trend in decreased bleeding and decreased incontinence.
A second systematic review of 25 studies, including some that were of lower quality, showed a higher recurrence rate at 1 year with stapled hemorrhoidectomy than with conventional surgery.5