You can help patients get to the bottom of hemorrhoid treatment options...since about 1 in 20 people in the US experience symptoms.
Direct patients through the myriad of OTC and Rx treatments.
Reinforce the basics. Recommend to avoid straining or prolonged bowel movements...and to manage constipation or diarrhea with fiber, fluids, etc.
Also consider med culprits (anticholinergics, opioids, iron, etc).
Suggest sitz baths after bowel movements to soothe irritation.
Tailor the choice of OTC topicals based on symptoms, dosage form, cost, etc. There are limited data to help guide recommendations...and most topicals provide temporary relief and lack long-term efficacy data.
Recent guidelines reinforce what we’re already doing.
For instance, use astringent wipes with witch hazel after bowel movements...to soothe burning and clean the area.
Consider protectants (zinc oxide, petrolatum, etc) to provide a barrier...and prevent irritation from passing stool.
Add a topical anesthetic (dibucaine, pramoxine, etc) for EXTERNAL pain and irritation. But don’t use these INSIDE the rectum...they won’t have much effect and may cause more irritation.
Think of phenylephrine products (Preparation H, etc) for internal OR external use...to reduce swelling and relieve burning, itching, etc.
In general, recommend combo products with a protectant, anesthetic, and phenylephrine...to simplify use and help with multiple symptoms.
If these aren’t enough, try hydrocortisone 1% cream short-term for more severe itching...or an oral analgesic for pain. Educate to limit topical steroid use to 7 days, unless a prescriber instructs otherwise.
Be aware, there’s no good evidence that Rx products (Anusol HC, Proctofoam HC, etc) work better than OTCs with similar ingredients.
Save compounded topical nitroglycerin or the 0.4% ointment (Rectiv) for anal fissures. These may relieve pain due to thrombosed external hemorrhoids...but have limited data, have drug interactions, and may cause headache.
Advise against the 2% ointment (Nitro-Bid)...it’s for angina.
Refer patients with hemorrhoids not responding to conservative treatments to their prescriber.
See our resource, Management of Constipation, for counseling points about lifestyle changes, fiber intake, OTCs, and more.
- Hawkins AT, Davis BR, Bhama AR, et al. Clinical Practice Guidelines Committee of the American Society of Colon and Rectal Surgeons. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2024 May 1;67(5):614-623.
- Mott T, Latimer K, Edwards C. Hemorrhoids: Diagnosis and Treatment Options. Am Fam Physician. 2018 Feb 1;97(3):172-179.
- Fox A, Tietze PH, Ramakrishnan K. Anorectal conditions: hemorrhoids. FP Essent. 2014 Apr;419:11-9.