Full Prescription for Hemorrhoids

1. Classification (Grading)

2. Step 1 - Conservative (Medical) Management

A. Dietary & Lifestyle Modifications (All grades - first line)

• Dietary fiber: Increase to 25-35 g/day via fruits, vegetables, whole grains, and psyllium husk. Evidence shows a 53% reduction in persistent symptoms with fiber supplementation.
• Fluid intake: 6-8 glasses of water per day.
• Avoid prolonged straining during defecation.
• Avoid prolonged sitting on the toilet.
• Sitz baths: Warm water 10-15 minutes, 2-3 times daily - helps reduce discomfort and spasm.
• Ice packs (for acute external thrombosis): reduces swelling and pain in the first 48 hours.

B. Bulk-Forming Agents (Rx/OTC)

C. Stool Softeners

D. Topical Agents (Symptom relief - pain, pruritus, swelling)

Note: Prolonged topical steroid use can cause allergic sensitization and skin atrophy. Limit to short courses.

E. Systemic Phlebotonic Agents

F. Analgesics (For acute pain)

3. Step 2 - Office-Based Procedures (Grade I-III failing conservative Rx)

4. Step 3 - Surgical Management (Grade III-IV, or failed office procedures)

5. Special Situations

Thrombosed External Hemorrhoid (TEH)

• If < 72 hours with peak pain: consider surgical excision (elliptical incision, not just incision/drainage) under local anesthesia (lidocaine 1% with epinephrine). Excision provides faster resolution and lower recurrence vs. incision alone.
• If > 72 hours (pain declining): conservative management - sitz baths, bulk agents, stool softeners, analgesia (acetaminophen +/- NSAIDs), topical nifedipine 0.2%/lidocaine or nitroglycerin 0.2%.

Incarcerated (Grade IV) Hemorrhoids

• Conservative: analgesia, stool softeners, sitz baths, ice
• Urgent surgery if conservative fails or gangrene develops

Hemorrhoids in Pregnancy

• First line: fiber, fluids, sitz baths, docusate sodium
• Topical: Hydrocortisone 1% + Pramoxine 1% foam (Proctofoam-HC) - safe in late pregnancy
• Avoid NSAIDs especially in third trimester
• Daflon 500 mg can be used cautiously in second trimester with physician supervision
• Most cases resolve postpartum

Hemorrhoids with Anticoagulation

• Avoid rubber band ligation - risk of serious hemorrhage
• Conservative measures preferred
• If surgical intervention needed, coordinate INR/anti-Xa management with hematology

6. Summary Algorithm

Symptomatic hemorrhoids
        |
        v
 Dietary + lifestyle modification
 Fiber 25-35g/day | Fluids | No straining
 Stool softeners | Sitz baths
        |
        v
 Add topical agents (pramoxine, HC cream) +/- phlebotonic (MPFF/Daflon)
        |
  ------+------
  |           |
Grade I-II  Grade III-IV
  |           |
  v           v
Office     Office (HAL/
procedure  banding) first
(RBL, IRC, attempt, then
sclerotherapy)  proceed to
              hemorrhoidectomy
                  |
                  v
            Ferguson or
           Milligan-Morgan
           hemorrhoidectomy

Key References

• ASCRS 2024 Management of Hemorrhoids Guidelines - Hawkins AT et al., Dis Colon Rectum 2024;67(5):614-623
• Phlebotonics Cochrane review (PMID 22895941): significant reduction in bleeding and symptoms
• Textbook of Family Medicine 9e - Anorectal Disease chapter
• Maingot's Abdominal Operations - Hemorrhoid Treatment

Disclaimer: This is a clinical reference guide. Individual patient factors (comorbidities, medications, pregnancy status, anticoagulation) must guide final prescribing decisions. Rectal bleeding should always be evaluated to exclude colorectal malignancy before attributing solely to hemorrhoids, especially in patients over 40 or with risk factors.

Advice Written Below the Prescription

Diet & Lifestyle Instructions:

• Drink 3-4 litres of water daily
• Eat high-fiber diet: green vegetables, fruits (papaya, guava), whole wheat, oats
• Avoid: spicy food, red meat, alcohol, caffeinated drinks
• Do not strain during defecation; limit toilet sitting time to < 5 minutes
• Sitz baths: Sit in warm water for 10-15 minutes — 2-3 times daily, especially after bowel movement
• Avoid prolonged sitting at work; take short walks every 1 hour
• Do not use dry, rough toilet paper — use soft wet wipes or water wash

Follow-up: Review after 2 weeks If bleeding persists or worsens, proctoscopy/anoscopy will be performed. If grade III-IV on evaluation, rubber band ligation will be planned.

Red flags — report immediately: Heavy rectal bleeding, fever, severe pain, inability to pass stool

Notes on This Prescription

• Daflon is the workhorse systemic agent - has the best evidence of any oral drug for hemorrhoids (Cochrane meta-analysis)
• Proctosedyl is a widely used real-world topical combining a local anesthetic (cinchocaine) with a steroid (hydrocortisone) - limited to 10 days to avoid steroid-related skin changes
• Ibuprofen is given cautiously for short-term pain only, and only if there is no active heavy bleeding
• Cremaffin + Dulcolax Softener together ensure easy, strain-free defecation during the healing period
• Psyllium continues long-term as a lifestyle modification - the single most evidence-backed conservative intervention
• Colonoscopy/sigmoidoscopy referral should be considered given the patient is 40 years old, per ASCRS 2024 guidelines, to rule out colorectal pathology if bleeding is the presenting complaint

"Sitz baths: Sit in warm water for 10–15 minutes, 2–3 times daily, especially after bowel movement"

Why Sitz Baths Are Important for Hemorrhoids

How to Do a Sitz Bath Correctly

1. Fill a bathtub or sitz bath basin with warm water (not hot) — about 40°C / 104°F
2. Sit with the perianal area submerged for 10–15 minutes
3. Repeat 2–3 times daily, and always after each bowel movement
4. Pat dry gently with a soft towel — do not rub
5. You can add a small amount of povidone-iodine or plain salt if there is discharge or local infection concern (though plain warm water is sufficient in most cases)

Sitcom Tablet = Euphorbia Prostrata Extract 100 mg tablet

About Euphorbia Prostrata (Sitcom)

How it works:

• Strengthens capillary walls - reduces bleeding by improving vascular integrity
• Reduces capillary permeability - decreases swelling and edema around hemorrhoids
• Venotonic effect - improves venous tone, reduces congestion in hemorrhoidal plexus
• Anti-inflammatory - reduces pain and discomfort
• Promotes wound healing - useful post-hemorrhoidectomy

Updated Prescription with Sitcom

Sitcom vs. Daflon - Which is better?