Hemorrhoids are swollen blood vessels in the anorectal region, commonly associated with straining during defecation, pregnancy, or prolonged sitting. Hemorrhoids can be external or internal relative to the rectum. If they are painful or itchy, they are mostly external.
According to the American College of Gastroenterology, the first step in hemorrhoid treatment is a trial of "conservative management" which can be done entirely at home without prescription or intervention.
First-line recommendations:
Dietary fiber: Increase to 20-30 g/day with increased fluid intake, avoidance of fatty foods, and regular physical activity. Metamucil 3-in-1 Fiber Capsules (FDA M007).
Warm sitz baths: A bath in which the buttocks are immersed in warm water for short periods of time. 2-3 times daily for 15-20 minutes. Sitz Bath for Hemorrhoids. Adding natural Epsom salts have been shown to significantly reduce pain relative to warm water alone during sitz baths.
Short-term laxative therapy: To soften stool and reduce irritation. Best initial treatment is polyethylene glycol (PEG). Start with 17 g or less dissolved in one cup of water daily as needed. Try this for 1-2 weeks to heal the hemorrhoid. MiraLAX Gentle Constipation Relief Laxative (FDA NDA 22015).
Treatment for pain and itching:
Lidocaine gel: If hemorrhoids are painful, you can use lidocaine, a topical anesthetic, for pain relief. Ebanel 4% Lidocaine Hemorrhoid Treatment (FDA M015) .
Vasoconstrictors: Phenylephrine HCl 0.25% can offer temporary symptomatic relief. Preparation H Cream (FDA M015) is cheaper but Preparation H Suppositories (FDA M015) are often more effective.
Hydrocortisone cream: If the hemorrhoid is itchy or painful, you can use hydrocortisone 1% cream for inflammation. Apply twice daily for up to 1 week. Preparation H Hydrocortisone 1% cream (FDA M017).
Seek medical attention and do not continue at-home management if you:
Do not experience symptom relief or resolution after 2 weeks
Have dark rectal bleeding
Have painless bleeding as this may indicate an internal hemorrhoid or inflammation of the rectum, which are treated with prescription suppositories
What a doctor may do:
In-office exam and/or colonoscopy
Prescription anti-inflammatory suppositories
Rubber band ligation for internal hemorrhoids.
Surgical hemorrhoidectomy for severe or refractory cases.
Citations:
Wald A, Bharucha AE, Limketkai B, et al. ACG Clinical Guidelines: Management of Benign Anorectal Disorders. Am J Gastroenterol. 2021; 116(10): p.1987-2008. doi: 10.14309/ajg.0000000000001507
Petersen, B. W., Arbuckle, H. A., & Berman, S. (2015). Effectiveness of saltwater baths in the treatment of epidermolysis bullosa. Pediatric Dermatology, 32(1), 60-63.
