For patients with edematous hemorrhoidal thrombosis, the first line of treatment is a nonsteroidal anti-inflammatory drug (NSAID), such as ketoprofen, in combination with an analgesic, as outlined by Vincent de Parades, MD, PhD, of Hôpital Paris Saint -Joseph, Paris. In his presentation from Annual Conference of General Medicine in France (JNMG 2024) regarding the management of hemorrhoidal disease, he noted, “This treatment (NSAIDs and analgesics) is highly effective, initially relieving pain and reducing edema, although the clot takes longer to resolve.” In cases where residual skin tags (marisques) remain after an episode, resection may be considered if they cause discomfort.

While patients often turn to over-the-counter topical treatments during flare-ups, de Parades noted that they have not been proven effective for hemorrhoid disease. For hemorrhoidal thrombosis, however, topical treatment with a corticosteroid and an anesthetic may be prescribed.

No NSAIDs for abscesses

In addition to NSAIDs, a topical treatment can provide soothing benefits, especially when combined with topical application, as Nadia Fathallah, MD, of Hôpital Paris Saint-Joseph, who joined de Parades in the presentation, pointed out. “I recommend massaging the salve to help dissolve the clot,” she added. However, “NSAIDs should not be prescribed for an abscess,” cautioned de Parades, stressing that “any patient with a painful anal swelling needs an exam.” If in doubt, administer an analgesic and reexamine the patient 1-2 days later. If an abscess is present, it will not resolve on its own and the pain will persist.

The two proctologists reviewed various interventions for the management of hemorrhoidal conditions, highlighting the benefits minimally invasive surgery as an alternative to hemorrhoidectomy for the treatment of grade 2 or 3 hemorrhoidal prolapse.

Hemorrhoidal disease involves abnormal dilation of the vascular system in the anus and rectum. External hemorrhoids affect the external vascular plexus, while internal hemorrhoids occur in the upper part of the anal canal at the internal plexus.

Hygiene and nutrition guide

Common symptoms include light to heavy bleeding during bowel movements and the sensation of a lump inside the anus. In some cases, this is accompanied by throbbing pain, which suggests hemorrhoidal thrombosis, a condition often associated with a painful external swelling. Prolapsed hemorrhoids, meanwhile, are characterized by the protrusion of internal hemorrhoids and are classified into four grades:

• Class 1: Hemorrhoids appear during straining, but do not protrude.
• Class 2: Hemorrhoids protrude, but spontaneously retract after straining.
• Class 3: Hemorrhoids protrude by straining and require manual reinsertion.
• Class 4: Prolapse is permanent.

In all cases, medical treatment is recommended as the initial approach. European guidelines I recommend implementing first lifestyle and dietary measuresencouraging regular physical activity and adequate water and fiber intake to promote intestinal transit. Laxatives may also be recommended.

Ligation of the elastic band

For hemorrhoidal thrombosis, NSAIDs and non-opioid analgesics are recommended as first-line treatments. For patients with contraindications to NSAIDs, such as pregnant women, treatment with corticosteroids can be administered, although it is less effective. The routine incision is no longer recommended, according to de Parades.

For prolapsed internal hemorrhoids, instrumental treatment is recommended as a second-line option if medical management fails for grades 1 and 2 or for isolated grade 3 hemorrhoids. With the phasing out of sclerotherapy injections, two options remain: infrared photocoagulation and ligation with elastic band.

The objective of instrumental treatment is to create a scar in the upper part of the hemorrhoidal plexus to reduce the vascularization and fix the hemorrhoid to the rectal wall. When performed correctly over the insensitive mucous area in the anal canal, the procedure is painless.

Ligation involves placing an elastic band at the base of the hemorrhoid, the intervention lasting only a few minutes. “Within 4 weeks, the hemorrhoids disappear,” explained de Parades. Photocoagulation is a more superficial treatment that requires several sessions spaced out, mainly to address bleeding.

Advances in minimally invasive surgery

Surgery is recommended if instrumental treatment fails and as a first-line option for grade 3 circular hemorrhoids (multiple hemorrhoidal masses) and grade 4 cases.

Milligan-Morgan hemorrhoidectomy is considered the “gold standard” surgical technique and is used primarily for grade 2, 3, and 4 cases. This technique involves resection of the three main hemorrhoidal fascicles while preserving the surrounding tissue, providing a ” radical and definitive”.

Although effective in the long term, hemorrhoid bundle resection requires a long healing process and usually requires the patient to take 15-20 days off work. It’s also not recommended for people who have anal sex, because “removal of hemorrhoidal tissue can reduce flexibility and sensation in the anal canal,” noted Fathallah.

Another technique widely used in France is Doppler-guided hemorrhoidal artery ligation, which selectively reduces blood flow to the hemorrhoidal plexus. It is often combined with a mucopexy to secure the prolapse above the anal canal and restore normal anatomy.

Minimally invasive surgery is today increasingly considered an alternative to hemorrhoidectomy for the treatment of grade 2 or 3 hemorrhoidal prolapse.

Laser and radiofrequency techniques induce coagulation of the submucosa, reducing arterial flow and creating fibrous tissue to retract the hemorrhoidal bundle. Because the procedure is applied above the anal canal, “it is associated with little or no pain.”

Hemorrhoidal embolization

Recent studies have validated the benefits of minimally invasive surgery for this condition. In a French multicenter studyradiofrequency treatment significantly improved quality of life 3 months after surgery, requiring only 4 days off work. The vast majority of patients declared themselves satisfied with the results.

The procedure is less uncomfortable than hemorrhoidectomy and allows for a faster recovery, but carries a risk of recurrence. In the French study, almost 8% of patients required reoperations within one year, mainly by haemorrhoidectomy. “The estimated recurrence rate is 20%-30% over a 10-year period,” de Parades said.

Overall, the specialist emphasized the value of surgery, including hemorrhoidectomy, in the treatment of hemorrhoidal prolapse. With substantial benefits from minimally invasive options, “patients should be referred early” to prevent progression of prolapse “which may leave no choice but hemorrhoidectomy.”

Finally, another technique is available for bleeding without prolapse: hemorrhoidal embolization. Practiced for about a decade, the procedure involves blocking blood flow to hemorrhoids by inserting tiny metal coils through a catheter, which is inserted transcutaneously through an artery in the arm.

This story was translated from Medscape French Edition using multiple editorial tools, including AI, as part of the process. Human editors reviewed this content prior to publication.