Editing Hemorrhoid (section)

==Management==
{{anchor|Treatments}}

===Conservative===
Conservative treatment typically consists of foods rich in [[dietary fiber]], intake of oral fluids to maintain hydration, [[nonsteroidal anti-inflammatory drug]]s, [[sitz bath]]s, and rest.<ref name=Review09 /> Increased fiber intake has been shown to improve outcomes<ref name=Alon2005>{{cite journal |last1 = Alonso-Coello |first1 = P. |last2 = Guyatt |first2 = G. H. |last3 = Heels-Ansdell |first3 = D. |last4 = Johanson |first4 = J. F. |last5 = Lopez-Yarto |first5 = M. |last6 = Mills |first6 = E. |last7 = Zhuo |first7 = Q. |last8 = Alonso-Coello |first8 = Pablo |title = Laxatives for the treatment of hemorrhoids |journal = Cochrane Database Syst Rev |issue = 4 |pages = CD004649 |year = 2005 |volume = 2010 |pmid = 16235372 |doi = 10.1002/14651858.CD004649.pub2 |pmc = 9036624 |editor1-last = Alonso-Coello |editor1-first = Pablo }}</ref> and may be achieved by dietary alterations or the consumption of [[fibre supplements|fiber supplements]].<ref name=Review09 /><ref name=Alon2005 /> Evidence for benefits from sitz baths during any point in treatment, however, is lacking.<ref>{{cite journal |last = Lang |first = DS |author2 = Tho, PC |author3 = Ang, EN |title = Effectiveness of the Sitz bath in managing adult patients with anorectal disorders |journal = Japan Journal of Nursing Science |date = December 2011 |volume = 8 |issue = 2 |pages = 115–28 |pmid = 22117576 |doi = 10.1111/j.1742-7924.2011.00175.x }}</ref> If they are used, they should be limited to 15 minutes at a time.<ref name=Beck2011 />{{rp|182}} Decreasing time spent on the toilet and not straining is also recommended.<ref name=Dav2018>{{cite journal|last1=Davis|first1=BR|last2=Lee-Kong|first2=SA|last3=Migaly|first3=J|last4=Feingold|first4=DL|last5=Steele|first5=SR|title=The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids.|journal=Diseases of the Colon and Rectum|date=March 2018|volume=61|issue=3|pages=284–92|doi=10.1097/DCR.0000000000001030|pmid=29420423|s2cid=4198610}}</ref>

While many [[topical agent]]s and [[suppositories]] are available for the treatment of hemorrhoids, little evidence supports their use.<ref name=Review09 /> As such, they are not recommended by the [[American Society of Colon and Rectal Surgeons]].<ref name="ASCRS2018" /> [[Steroid]]-containing agents should not be used for more than 14 days, as they may cause thinning of the skin.<ref name=Review09 /> Most agents include a combination of active ingredients.<ref name=Beck2011 /> These may include a barrier cream such as [[petroleum jelly]] or [[zinc oxide]], an analgesic agent such as [[lidocaine]], and a [[vasoconstrictor]] such as [[epinephrine]].<ref name=Beck2011 /> Some contain [[Balsam of Peru]] to which certain people may be allergic.<ref name="dermnetnz1">{{cite web |url = http://dermnetnz.org/dermatitis/balsam-of-peru-allergy.html |title = Balsam of Peru contact allergy |publisher = Dermnetnz.org |date = December 28, 2013 |access-date = March 5, 2014 |url-status = live |archive-url = https://web.archive.org/web/20140305094411/http://dermnetnz.org/dermatitis/balsam-of-peru-allergy.html |archive-date = March 5, 2014 }}</ref><ref>{{cite book |title = The ASCRS Textbook of Colon and Rectal Surgery: Second Edition |year = 2011 |isbn = 978-1-4419-1581-8 |url = https://books.google.com/books?id=DhQ1A35E8jwC&pg=PA280 |url-status = live |archive-url = https://web.archive.org/web/20140704121836/http://books.google.com/books?id=DhQ1A35E8jwC&pg=PA280 |archive-date = 2014-07-04 |last1 = Beck |first1 = David E. |last2 = Roberts |first2 = Patricia L. |last3 = Saclarides |first3 = Theodore J. |last4 = Senagore |first4 = Anthony J. |last5 = Stamos |first5 = Michael J. |last6 = Nasseri |first6 = Yosef |publisher = Springer }}</ref>

[[Flavonoids]] are of questionable benefit, with potential side effects.<ref name=Beck2011 /><ref>{{cite journal |vauthors = Alonso-Coello P, Zhou Q, Martinez-Zapata MJ, etal |title = Meta-analysis of flavonoids for the treatment of haemorrhoids |journal = Br J Surg |volume = 93 |issue = 8 |pages = 909–20 |date = August 2006 |pmid = 16736537 |doi = 10.1002/bjs.5378 |s2cid = 45532404 |doi-access = free }}</ref> Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery.<ref>{{cite journal |last = Quijano |first = CE |author2 = Abalos, E |title = Conservative management of symptomatic and/or complicated haemorrhoids in pregnancy and the puerperium |journal = Cochrane Database of Systematic Reviews |date = Jul 20, 2005 |volume = 2012 |issue = 3 |pages = CD004077 |pmid = 16034920 |doi = 10.1002/14651858.CD004077.pub2 |pmc = 8763308 }}</ref> Evidence does not support the use of [[Traditional Chinese medicine|traditional Chinese herbal treatment]].<ref>{{Cite journal|issue = 10|pages = CD006791|last1=Gan|first1=Tao|last2=Liu|first2=Yue-dong|last3=Wang|first3=Yiping|last4=Yang|first4=Jinlin|date=2010-10-06|language=en|doi=10.1002/14651858.cd006791.pub2|pmid = 20927750|title = Traditional Chinese Medicine herbs for stopping bleeding from haemorrhoids|journal = Cochrane Database of Systematic Reviews}}</ref>

The use of [[phlebotonics]] has been investigated in the treatment of low-grade hemorrhoids,<ref name="ASCRS2018">{{cite journal |last1=Davis |first1=BR |last2=Lee-Kong |first2=SA |last3=Migaly |first3=J |last4=Feingold |first4=DL |last5=Steele |first5=SR |title=The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. |journal=Diseases of the Colon and Rectum |date=March 2018 |volume=61 |issue=3 |pages=284–292 |doi=10.1097/DCR.0000000000001030 |pmid=29420423 |s2cid=4198610 |type=Professional society guidelines}}</ref><ref name="Perera2012">{{cite journal |last1=Perera |first1=Nirmal |last2=Liolitsa |first2=Danae |last3=Iype |first3=Satheesh |last4=Croxford |first4=Anna |last5=Yassin |first5=Muhammed |last6=Lang |first6=Peter |last7=Ukaegbu |first7=Obioha |last8=van Issum |first8=Christopher |title=Phlebotonics for haemorrhoids |journal=Cochrane Database of Systematic Reviews |issue=8 |pages=CD004322 |date=15 August 2012 |doi=10.1002/14651858.CD004322.pub3 |pmid=22895941|s2cid=28445593 |pmc=11930390 }}</ref><ref>{{cite journal |last1=Higuero |first1=T |last2=Abramowitz |first2=L |last3=Castinel |first3=A |last4=Fathallah |first4=N |last5=Hemery |first5=P |last6=Laclotte Duhoux |first6=C |last7=Pigot |first7=F |last8=Pillant-Le Moult |first8=H |last9=Senéjoux |first9=A |last10=Siproudhis |first10=L |last11=Staumont |first11=G |last12=Suduca |first12=JM |last13=Vinson-Bonnet |first13=B |title=Guidelines for the treatment of hemorrhoids (short report). |journal=Journal of Visceral Surgery |date=June 2016 |volume=153 |issue=3 |pages=213–8 |doi=10.1016/j.jviscsurg.2016.03.004 |pmid=27209079 |type=Professional society guidelines|doi-access= }}</ref><ref>{{cite journal |last1=Trompetto |first1=M. |last2=Clerico |first2=G. |last3=Cocorullo |first3=G. F. |last4=Giordano |first4=P. |last5=Marino |first5=F. |last6=Martellucci |first6=J. |last7=Milito |first7=G. |last8=Mistrangelo |first8=M. |last9=Ratto |first9=C. |title=Evaluation and management of hemorrhoids: Italian society of colorectal surgery (SICCR) consensus statement |journal=Techniques in Coloproctology |date=24 September 2015 |volume=19 |issue=10 |pages=567–575 |doi=10.1007/s10151-015-1371-9|pmid=26403234 |hdl=10447/208054 |s2cid=30827065 |hdl-access=free }}</ref> although these drugs are not approved for such use in the United States or Germany.<ref>{{cite book |last1=Garg |first1=Nitin |last2=Gloviczki |first2=Peter |title=Vascular Medicine: A Companion to Braunwald's Heart Disease |date=2013 |publisher=Elsevier Health Sciences |isbn=9781437729306 |pages=652–666 |chapter-url=https://www.sciencedirect.com/science/article/pii/B9781437729306000550 |chapter=55—Chronic Venous Insufficiency|edition=Second }}</ref><ref name="Stucker2016">{{cite journal |last1=Stücker |first1=M |last2=Debus |first2=ES |last3=Hoffmann |first3=J |last4=Jünger |first4=M |last5=Kröger |first5=K |last6=Mumme |first6=A |last7=Ramelet |first7=AA |last8=Rabe |first8=E |title=Consensus statement on the symptom-based treatment of chronic venous diseases. |journal=Journal of the German Society of Dermatology |date=June 2016 |volume=14 |issue=6 |pages=575–83 |doi=10.1111/ddg.13006 |pmid=27240062 |type=Professional society guidelines|doi-access=free }}</ref> The use of phlebotonics for the treatment of chronic venous diseases is restricted in Spain.<ref>{{cite web |title=Consolidated List of Products—Whose Consumption and/or Sale Have Been Banned, Withdrawn, Severely Restricted or Not Approved by Governments, Twelfth Issue—Pharmaceuticals. United Nations—New York, 2005 |url=http://apps.who.int/medicinedocs/en/m/abstract/Js16780e/ |archive-url=https://web.archive.org/web/20141108234228/http://apps.who.int/medicinedocs/en/m/abstract/Js16780e/ |url-status=dead |archive-date=November 8, 2014 |website=apps.who.int |access-date=7 November 2019 |date=2005}}</ref>

===Procedures===
A number of office-based procedures may be performed. While generally safe, rare serious side effects such as [[sepsis|perianal sepsis]] may occur.<ref name=NG2011 />

# '''[[Rubber band ligation]]''' is typically recommended as the first-line treatment in those with '''grade I to III disease'''.<ref name="NG2011" /> It is a procedure in which elastic bands are applied onto internal hemorrhoid at least 1&nbsp;cm above the pectinate line to cut off its blood supply.<!-- <ref name=Review09 /> --> Within 5–7 days, the withered hemorrhoid falls off.<!-- <ref name=Review09 /> --> If the band is placed too close to the pectinate line, intense pain results immediately afterwards.<ref name="Review09" /> The cure rate has been found to be about 87%,<ref name="Review09" /> with a complication rate of up to 3%.<ref name="NG2011" />
# '''[[Sclerotherapy]]''' involves the injection of a [[sclerosing]] agent, such as [[phenol]], into the hemorrhoid. This causes the vein walls to collapse and the hemorrhoids to shrivel up. The success rate four years after treatment is about 70%.<ref name="Review09" />
# A number of '''[[cauterization]]''' methods have been shown to be effective for hemorrhoids, but are usually used only when other methods fail. This procedure can be done using [[electrocautery]], [[infrared radiation]], [[laser surgery]],<ref name="Review09" /> or [[cryosurgery]].<ref>{{cite journal |last = Misra |first = MC |author2 = Imlitemsu |title = Drug treatment of haemorrhoids |journal = Drugs |year = 2005 |volume = 65 |issue = 11 |pages = 1481–91 |pmid = 16134260 |doi = 10.2165/00003495-200565110-00003 |s2cid = 33128093 }}</ref> Infrared cauterization may be an option for '''grade I or II disease'''.<ref name="NG2011" /> In those with '''grade III or IV disease''', reoccurrence rates are high.<ref name="NG2011" />
[[Hemorrhoidal artery embolization|Hemorrhoidal artery embolization (HAE)]] is an additional minimally invasive procedure performed by an [[Interventional radiology|interventional radiologist]].<ref name=":0">{{Cite web |title=Hemorrhoidal Artery Embolization (HAE) |url=https://www.uclahealth.org/medical-services/radiology/interventional-radiology/HAE |access-date=2024-07-18 |website=www.uclahealth.org |language=en}}</ref> HAE involves the blockage of abnormal blood flow to the rectal (hemorrhoidal) arteries using microcoils and/or [[microparticle]]s to decrease the size of the hemorrhoids and improve hemorrhoid related symptoms, especially bleeding.<ref name=":1">{{Cite AV media |url=https://www.youtube.com/watch?v=Whje31Jlm10 |title=Hemorrhoidal Artery Embolization Minimally Invasive Treatment for Symptomatic Internal Hemorrhoids |date=2024-06-24 |last=UCLA Health |access-date=2024-07-18 |via=YouTube}}</ref> HAE is very effective at stopping bleeding related symptom with success rate of approximately 90%.<ref name=":3">{{Cite journal |last1=Makris |first1=Gregory C. |last2=Thulasidasan |first2=Narayan |last3=Malietzis |first3=George |last4=Kontovounisios |first4=Christos |last5=Saibudeen |first5=Affan |last6=Uberoi |first6=Raman |last7=Diamantopoulos |first7=Athanasios |last8=Sapoval |first8=Marc |last9=Vidal |first9=Vincent |date=January 2021 |title=Catheter-Directed Hemorrhoidal Dearterialization Technique for the Management of Hemorrhoids: A Meta-Analysis of the Clinical Evidence |url=https://doi.org/10.1016/j.jvir.2021.03.548 |journal=Journal of Vascular and Interventional Radiology |volume=32 |issue=8 |pages=1119–1127 |doi=10.1016/j.jvir.2021.03.548 |pmid=33971251 |issn=1051-0443}}</ref>

===Surgery===
A number of surgical techniques may be used if conservative management and simple procedures fail.<ref name=NG2011 /> All surgical treatments are associated with some degree of complications, including bleeding, infection, [[anal stricture]]s, and [[urinary retention]], due to the close proximity of the rectum to the nerves that supply the bladder.<ref name=Review09 /> Also, a small risk of [[fecal incontinence]] occurs, particularly of liquid,<ref name=Beck2011 /><ref name="Pescatori 2008">{{cite journal |last = Pescatori |first = M |author2 = Gagliardi, G |title = Postoperative complications after procedure for prolapsed hemorrhoids (PPH) and stapled transanal rectal resection (STARR) procedures |journal = Techniques in Coloproctology |date = March 2008 |volume = 12 |issue = 1 |pages = 7–19 |pmid = 18512007 |doi = 10.1007/s10151-008-0391-0 |pmc = 2778725 }}</ref> with rates reported between 0% and 28%.<ref>{{cite journal |last = Ommer |first = A |author2 = Wenger, FA |author3 = Rolfs, T |author4 = Walz, MK |title = Continence disorders after anal surgery—a relevant problem? |journal = International Journal of Colorectal Disease |date = November 2008 |volume = 23 |issue = 11 |pages = 1023–31 |pmid = 18629515 |doi = 10.1007/s00384-008-0524-y |s2cid = 7247471 }}</ref> Mucosal [[ectropion]] is another condition which may occur after hemorrhoidectomy (often together with anal stenosis).<ref name=Garcia2002>{{cite journal |last = Lagares-Garcia |first = JA |author2 = Nogueras, JJ |title = Anal stenosis and mucosal ectropion |journal = The Surgical Clinics of North America |date = December 2002 |volume = 82 |issue = 6 |pages = 1225–31, vii |pmid = 12516850 |doi = 10.1016/s0039-6109(02)00081-6 }}</ref> This is where the anal mucosa becomes everted from the anus, similar to a very mild form of [[rectal prolapse]].<ref name=Garcia2002 />
# '''Excisional hemorrhoidectomy''' is a surgical excision of the hemorrhoid used primarily only in severe cases.<ref name="Review09" /> It is associated with significant postoperative pain and usually requires two to four weeks for recovery.<ref name="Review09" /> However, the long-term benefit is greater in those with '''grade III hemorrhoids''' as compared to rubber band ligation.<ref>{{cite journal |last = Shanmugam |first = V |author2 = Thaha, MA |author3 = Rabindranath, KS |author4 = Campbell, KL |author5 = Steele, RJ |author6 = Loudon, MA |title = Rubber band ligation versus excisional haemorrhoidectomy for haemorrhoids |journal = Cochrane Database of Systematic Reviews |date = Jul 20, 2005 |volume = 2011 |issue = 3 |pages = CD005034 |pmid = 16034963 |doi = 10.1002/14651858.CD005034.pub2 |pmc = 8860341 }}</ref> It is the recommended treatment in those with a [[perianal hematoma|thrombosed external hemorrhoid]] if carried out within 24–72 hours.<ref name="NG2011" /><ref name="Day2006">{{cite book |last = Dayton |first = Peter F. Lawrence, Richard Bell, Merril T. |title = Essentials of general surgery |year = 2006 |publisher = Williams & Wilkins |location = Philadelphia; Baltimore |isbn = 978-0-7817-5003-5 |page = 329 |url = https://books.google.com/books?id=QOeHP5Ky610C&pg=PA329 |edition = 4th |url-status = live |archive-url = https://web.archive.org/web/20170908184817/https://books.google.com/books?id=QOeHP5Ky610C&pg=PA329 |archive-date = 2017-09-08 }}</ref> Evidence to support this is weak, however.<ref name="Dav2018" /> [[Glyceryl trinitrate (pharmacology)|Glyceryl trinitrate]] ointment after the procedure helps both with pain and with healing.<ref>{{cite journal |last = Ratnasingham |first = K |author2 = Uzzaman, M |author3 = Andreani, SM |author4 = Light, D |author5 = Patel, B |title = Meta-analysis of the use of glyceryl trinitrate ointment after haemorrhoidectomy as an analgesic and in promoting wound healing |journal = International Journal of Surgery |year = 2010 |volume = 8 |issue = 8 |pages = 606–11 |pmid = 20691294 |doi = 10.1016/j.ijsu.2010.04.012 |doi-access = free }}</ref>
# '''Doppler-guided [[transanal hemorrhoidal dearterialization]]''' is a minimally invasive treatment using an ultrasound Doppler to accurately locate the arterial blood inflow. These arteries are then "tied off" and the prolapsed tissue is sutured back to its normal position. It has a slightly higher recurrence rate but fewer complications compared to a hemorrhoidectomy.<ref name="Review09" />
# '''Stapled hemorrhoidectomy''', also known as '''[[stapled hemorrhoidopexy]]''', involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomical position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids.<ref name="Review09" /> However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorrhoidectomy,<ref name="Jaya2006">{{cite journal |last = Jayaraman |first = S |author2 = Colquhoun, PH |author3 = Malthaner, RA |title = Stapled versus conventional surgery for hemorrhoids |journal = Cochrane Database of Systematic Reviews |date = Oct 18, 2006 |volume = 2010 |issue = 4 |pages = CD005393 |pmid = 17054255 |doi = 10.1002/14651858.CD005393.pub2 |pmc = 8887551 }}</ref> so it is typically recommended only for '''grade II or III disease'''.<ref name="NG2011" />