Conservative Conservative treatment typically consists of nutrition rich in dietary fiber, uptake of oral fluids to maintain hydration, non-steroidal anti-inflammatory drugs (NSAID)s, sitz baths, and rest. Increased fiber intake has been shown to improve outcomes, and may be achieved by dietary alterations or the consumption of fiber supplements. Evidence for benefits from sitz baths during any point in treatment however is lacking. If they are used they should be limited to 15 minutes at a time. While many topical agents and suppositories are available for the treatment of hemorrhoids, there is little evidence to support their use. Steroid containing agents should not be used for more than 14 days as they may cause thinning of the skin. Most agents include a combination of active ingredients. 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. Flavonoids are of questionable benefit with potential side effects. Symptoms usually resolve following pregnancy; thus active treatment is often delayed until after delivery. Procedures A number of office based procedures may be performed. While generally safe, rare serious side effects such as perianal sepsis may occur. Rubber band ligation is typically recommended as the first line treatment in those with grade 1 to 3 disease. It is a procedure in which elastic bands are applied onto an internal hemorrhoid at least 1 cm above the dentate line to cut off its blood supply. Within 5–7 days, the withered hemorrhoid falls off. If the band is placed too close to the dentate line, intense pain results immediately afterwards. Cure rate has been found to be about 87% with a complication rate of up to 3%. 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 ~70% which is higher than that with rubber band ligation. A number of cauterization methods have been shown to be effective for hemorrhoids, but are usually only used when other methods fail. This procedure can be done using electrocautery, infrared radiation, laser surgery, or cryosurgery. Infrared cauterization may be an option for grade 1 or 2 disease. In those with grade 3 or 4 disease re-occurrence rates are high. Surgery A number of surgical techniques may be used if conservative management and simple procedures fail. All surgical treatments are associated with some degree of complications including bleeding, infection, anal strictures and urinary retention, due to the close proximity of the rectum to the nerves that supply the bladder. There may also be a small risk of fecal incontinence, particularly of liquid, with rates reported between 0% and 28%. Mucosal ectropion is another condition which may occur after hemorrhoidectomy (often together with anal stenosis). This is where the anal mucosa becomes everted from the anus, similar to a very mild form of rectal prolapse. Excisional hemorrhoidectomy is a surgical excision of the hemorrhoid used primarily only in severe cases. It is associated with significant post-operative pain and usually requires 2–4 weeks for recovery. However, there is greater long term benefit in those with grade 3 hemorrhoids as compared to rubber band ligation. It is the recommended treatment in those with a thrombosed external hemorrhoid if carried out within 24–72 hours. Glyceryl trinitrate ointment post procedure, helps both with pain and healing. 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. Stapled hemorrhoidectomy, also known as stapled hemorrhoidopexy, is a procedure that involves the removal of much of the abnormally enlarged hemorrhoidal tissue, followed by a repositioning of the remaining hemorrhoidal tissue back to its normal anatomic position. It is generally less painful and is associated with faster healing compared to complete removal of hemorrhoids. However, the chance of symptomatic hemorrhoids returning is greater than for conventional hemorroidectomy and thus it is typically only recommended for grade 2 or 3 disease.