Write me two prescription. 1st of a grade 2 internal haemmoroid and 2 nd of a external haemmoroid. Include 1st line and 2 nd line medical treatment only since patient don't want surgery now.
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haemorrhoid grade 2 internal external medical treatment first line second line prescription 2024
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I now have comprehensive information from the textbooks and current ASCRS 2024 guidelines. Let me compose the two prescriptions.
Prescription 1 — Grade II Internal Haemorrhoid
Patient: _____________________ Date: 18 May 2026
Diagnosis: Grade II Internal Haemorrhoid (bleeds + prolapses with defecation; reduces spontaneously)
🥇 FIRST LINE — Conservative / Dietary Measures (All Patients)
| Rx | Drug / Intervention | Dose & Instructions |
|---|---|---|
| 1 | Psyllium husk (Isabgol / Metamucil) | 1 teaspoon (3.4 g) in 240 mL water twice daily with meals. Target: 20–30 g dietary fibre/day total |
| 2 | Docusate sodium 100 mg oral cap | 1 cap twice daily with a full glass of water — stool softener; use while stools remain hard |
| 3 | Hydration counselling | 6–8 glasses non-alcoholic, non-caffeinated fluid daily |
| 4 | Sitz bath | Warm water 15 min, 2–3×/day and after each bowel movement |
| 5 | Topical: Phenylephrine 0.25% + Petrolatum/Mineral oil (e.g. Preparation H ointment) | Apply to the anal area twice daily and after each bowel movement — for swelling and pruritus relief |
Lifestyle advice:
- Avoid straining and prolonged sitting on the toilet (max 5 min per sitting)
- Avoid heavy lifting; increase physical activity
- Review and improve dietary fibre intake (diet diary recommended)
🥈 SECOND LINE — If Bleeding/Symptoms Persist > 4–6 Weeks on 1st Line
| Rx | Drug / Intervention | Dose & Instructions |
|---|---|---|
| 6 | Micronised Purified Flavonoid Fraction (MPFF) — Diosmin 450 mg + Hesperidin 50 mg (e.g. Daflon 500 mg, Vasculara) | 2 tablets twice daily for acute bleed for 4 days, then 1 tablet twice daily for 3 months as maintenance. Superior to placebo for bleeding; improves venous tone and capillary permeability |
| 7 | Topical corticosteroid: Hydrocortisone acetate 1% + Lidocaine 1% anorectal cream (e.g. Anusol-HC, Proctosedyl) | Apply sparingly twice daily for ≤ 14 days for pain/pruritus relief. Caution: do not use > 2 weeks — risk of candidiasis and skin atrophy |
| 8 | Polyethylene glycol 3350 (Macrogol / MiraLAX) 17 g sachet | 1 sachet in 240 mL water once daily — if fibre alone fails to normalise stool consistency |
| 9 | Oral analgesic (if pain/discomfort): Paracetamol 500 mg | 1–2 tablets every 6–8 hours PRN; avoid NSAIDs (may worsen bleeding) |
| 10 | Sclerotherapy / Infrared photocoagulation (office-based, non-surgical — patient to be counselled) | If medical Rx fails: 5% Phenol in oil sclerosant injection at apex of haemorrhoid column — very effective for Grade I–II. Outpatient, no anaesthesia needed |
If no response to the above: Rubber Band Ligation (RBL) is the most effective office-based non-surgical procedure for Grade II (and III) haemorrhoids — to be offered when patient is ready.
Prescription 2 — External Haemorrhoid (Thrombosed / Symptomatic)
Patient: _____________________ Date: 18 May 2026
Diagnosis: External Haemorrhoid (Thrombosed) — painful tender perianal mass
(Note: External haemorrhoids arise below the dentate line, covered by squamous epithelium; thrombosis is the most common acute presentation)
🥇 FIRST LINE — Conservative Management
| Rx | Drug / Intervention | Dose & Instructions |
|---|---|---|
| 1 | Sitz bath | Warm water 15 min, 3–4×/day and after each bowel movement — reduces oedema and pain |
| 2 | Psyllium husk (Isabgol) | 1 teaspoon (3.4 g) in 240 mL water twice daily — bulk-forming agent to prevent straining |
| 3 | Paracetamol 500 mg | 2 tablets every 6–8 hours PRN for pain (max 4 g/day) |
| 4 | Ibuprofen 400 mg oral | 1 tablet three times daily with food for 5 days — reduces perianal inflammation and swelling. Avoid if peptic ulcer history; add PPI cover if needed |
| 5 | Topical: Lidocaine 5% ointment (or Nifedipine 0.2% + Lidocaine 1.5% gel) | Apply sparingly to the external haemorrhoid 3–4×/day for local anaesthesia and smooth muscle relaxation; reduces acute pain significantly |
| 6 | Topical Heparinoid cream (e.g. Hirudoid / Thrombophob) | Apply 2–3×/day over the thrombosed external haemorrhoid — promotes clot resolution, reduces inflammation |
Natural history counselling:
- Pain typically peaks at 48–72 hours then subsides over 3–5 days
- Condition is self-limiting; resolves over a few weeks without surgery in most cases
- Warm sitz baths, analgesia and stool softeners are the mainstay beyond 72 hours
🥈 SECOND LINE — Persistent Pain / Refractory Cases (Non-Surgical)
| Rx | Drug / Intervention | Dose & Instructions |
|---|---|---|
| 7 | MPFF — Diosmin 450 mg + Hesperidin 50 mg (Daflon 500 mg) | 2 tablets twice daily for 4 days, then 2 tablets once daily for 3 days — phlebotonic; reduces oedema, capillary permeability; evidence for reducing acute symptoms |
| 8 | Topical Nifedipine 0.3% cream ± Lidocaine 1.5% | Apply twice daily for 2 weeks — calcium-channel blocker causes smooth muscle relaxation, reduces internal sphincter spasm and perianal pain; shown to accelerate resolution of thrombosed external haemorrhoids |
| 9 | Docusate sodium 100 mg | 1 cap twice daily — stool softener, ensures soft easy-to-pass stools, prevents straining and pressure on haemorrhoid |
| 10 | Oral tramadol 50 mg (if pain is severe, > 72 h) | 1 tablet every 6–8 hours PRN for maximum 3–5 days — reserve for severe uncontrolled pain. Caution: constipating; combine with stool softener |
Note: RBL, sclerotherapy, and infrared coagulation are not applicable to external haemorrhoids — they are reserved strictly for internal haemorrhoids above the dentate line.
If thrombosis presents within 72 hours and pain is still rising, office thrombectomy (incision under local anaesthetic, clot evacuation) may be offered as an intermediate step before any surgical haemorrhoidectomy is considered.
References:
- Sleisenger & Fordtran's Gastrointestinal and Liver Disease, Treatment of Haemorrhoids section
- Mulholland & Greenfield's Surgery: Scientific Principles and Practice, 7e, Thrombosed External Haemorrhoids
- Pfenninger & Fowler's Procedures for Primary Care, Chapter 106 — Grading and treatment options
- ASCRS Clinical Practice Guidelines for the Management of Hemorrhoids, Dis Colon Rectum, May 2024
⚠️ Prescriber note: Grade II internal haemorrhoids and symptomatic external haemorrhoids are both amenable to sustained medical management. If first and second line therapy fails after 6–12 weeks, re-discuss office-based procedures (sclerotherapy, RBL for internal; thrombectomy for acute external) before escalating to surgical haemorrhoidectomy.
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