Approach

The main aim of treatment is relief of symptoms. The treatment depends on whether the symptomatic haemorrhoids are internal, external, or a combination of both. Grading of internal haemorrhoids does not reflect disease severity or size of prolapse, but may aid in choosing treatment method.

All patients should be offered information about lifestyle and dietary modification, specifically increased fibre intake, adequate fluids, and not spending excessive time sitting at stool.[1][13]​​[14]​ Oral laxatives such as polyethylene glycol or docusate sodium may be given to patients who are unable to increase their dietary fibre intake.[1]​​[14] Other basic treatments may include topical treatments and analgesics.[14]

Mild intermittent bleeding

If the patient presents with mild intermittent bleeding, diet and lifestyle modifications to prevent constipation are usually all that are required to treat the haemorrhoids. Occasional short-term use of topical corticosteroids may soothe pruritic symptoms; however, prolonged use can cause allergic reactions or sensitisation, and there is no robust evidence to recommend their long-term use.[13]​​

A thorough evaluation including endoscopic exam is warranted to exclude a more serious diagnosis.

Internal haemorrhoids

Rubber band ligation is a simple and effective method of managing excess tissue and is the treatment of choice for grade 1 or 2 haemorrhoids that are unresponsive to conservative management.[1][13]​​[14]​ 

Rubber band ligation is performed with the aid of an anoscope. A rubber band is placed on the redundant haemorrhoidal tissue, with care taken to place the bands above the dentate line. The tissue contained in the band necroses and sloughs in approximately 1 week; success rates for controlling haemorrhoidal disease are good.[15]​ Alternatively, rubber bands can be placed at the same time as a colonoscopy.[15]​ Patients can experience transient bleeding or, extremely rarely, septic events. Anticoagulants should be withheld before performing rubber band ligation, and any bleeding after the procedure should be promptly evaluated.

Sclerotherapy and infrared coagulation may be more suitable for haemorrhoids that are too small for rubber band ligation (which may include grade 1 to 2 haemorrhoids).[1]​​ Both have similar effects and may require multiple treatment sessions to successfully ablate the tissue.[1][13]​​ Sclerotherapy involves injecting a chemical agent directly into the haemorrhoidal tissue to cause local tissue destruction and scarring of the haemorrhoidal tissue. Infrared coagulation uses infrared radiation applied directly to the haemorrhoid, which causes coagulation, scarring, and subsequent fixation of the internal haemorrhoidal tissue.[1][13]​​ Both sclerotherapy and infrared coagulation are office procedures and do not require anaesthesia.

Haemorrhoid artery ligation (also known as transanal haemorrhoidal de-arterialisation) is an option for grade 2 or 3 haemorrhoids.[14]​ Haemorrhoid artery ligation utilises a custom-designed proctoscope coupled with a Doppler transducer to identify and ligate the terminal branches of superior rectal artery above the dentate line (resulting in haemorrhoidal shrinkage). The procedure is commonly done under a short general anaesthetic and multiple ligations may be required.[16][17]​ Patients with grade 2 or 3 haemorrhoids who were randomised to haemorrhoidal arterial ligation experienced fewer recurrences at 1 year than patients treated with rubber band ligation.[18] However, symptom scores and complications did not differ between treatment groups, and patients treated with haemorrhoidal arterial ligation had more early postoperative pain.[18]

Rubber band ligation remains a reasonable choice for grade 3 haemorrhoids.[1][13]​​[14]​ However, patients with large grade 3 haemorrhoids (in addition to patients refractory to or who cannot tolerate outpatient procedures; patients with large, symptomatic external tags; or patients with grade 4 haemorrhoids) are candidates for surgery (haemorrhoidectomy, stapled haemorrhoidopexy, haemorrhoid artery ligation).[1][13]​​ In a small study of patients with grade 3 or small grade 4 haemorrhoids, rubber band ligation and stapled haemorrhoidopexy (in which prolapsing haemorrhoids are relocated within the anal canal, rather than excised) were equally effective in controlling symptomatic prolapse, but rubber band ligation was associated with an increased risk of recurrent bleeding.[19] Stapled haemorrhoidopexy was associated with increased pain and analgesia use at 2-week and at 2-month follow-up; the two treatment groups did not differ with respect to patient satisfaction or quality of life.[19] However, guidelines recommend against routine use of stapled haemorrhoidopexy as a first-line surgical option due to an increased risk of complications and recurrence.[1][13]​ Patients should be informed of the potential for symptomatic recurrence following stapled haemorrhoidopexy.[20][21]

Surgical haemorrhoidectomy is the most effective first-line approach for grade 4 internal haemorrhoids.[13][14]​ One network meta-analysis that included patients undergoing elective surgery for grade 3 to 4 haemorrhoids found that conventional haemorrhoidectomy was associated with greater postoperative pain but fewer haemorrhoid recurrences than stapled haemorrhoidopexy.[22] Another network meta-analysis of studies involving surgical procedures for grade 3 or 4 haemorrhoids found haemorrhoid artery ligation and stapled haemorrhoidopexy were associated with more complications and higher recurrence rates than open haemorrhoidectomy and the use of an ultrasonic scalpel. In addition, open haemorrhoidectomy resulted in fewer complications but a higher recurrence rate and the use of an ultrasonic scalpel resulted in more complications but a lower recurrence rate.[23] A large, open-label pragmatic trial of 777 patients referred to hospital for surgical treatment of haemorrhoids (including grade 4) found that patients who received stapled haemorrhoidopexy had less short-term pain.[24][25] However, recurrence rates, symptoms, re-interventions and quality-of-life measures all favoured traditional haemorrhoidectomy.[24][25] Meta-analyses have found that stapled haemorrhoidopexy and haemorrhoidal artery ligation were both effective treatments for haemorrhoids but stapled haemorrhoidopexy resulted in a lower recurrence rate.[26][27]

External or combined internal and external haemorrhoids

For external haemorrhoids, or combined internal and external haemorrhoids with severe symptoms, surgical excision may be the only effective treatment option.[13]​ This involves excision under either a general or regional anaesthetic. Asymptomatic external haemorrhoids do not warrant invasive treatment but may be observed while the patient follows dietary and lifestyle modification.

In thrombosis of external haemorrhoids, minimally invasive procedures such as de-roofing may be required for symptom relief, which can be done under topical, regional, or general anaesthetic.

Early haemorrhoidectomy is likely to increase speed of symptom resolution, reduce the chance of recurrence, and provide longer periods of remission compared to conservative management alone.[1][13]​​[28]

Haemorrhoids during pregnancy

Pregnant and postnatal women have a higher incidence of haemorrhoids. A non-operative approach is recommended, with basic treatment including laxatives, topical treatments, and analgesics.​[2][14]​​ Surgical haemorrhoid removal is rarely an appropriate intervention for pregnant women as haemorrhoidal symptoms often resolve spontaneously after birth, but it may be considered in extreme circumstances.[29][30]

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