{ "slug": "do-hemorrhoids-go-away", "question": "Do hemorrhoids go away on their own, and how long does it take?", "shortTitle": "Do Hemorrhoids Go Away on Their Own?", "clinicalQuestion": "In adults with symptomatic hemorrhoids (internal, external, or skin tags), what is the natural history without procedural treatment, including the proportion that resolve spontaneously and the time to symptom resolution?", "pico": { "population": "Adults with symptomatic internal or external hemorrhoids, including hemorrhoidal skin tags", "intervention": "No treatment or conservative management (fiber, sitz baths, topical agents, lifestyle changes) watched over time", "comparator": "Procedural or surgical treatment, or baseline symptom state", "outcomes": [ "Proportion of patients with spontaneous symptom resolution", "Time to resolution of pain, bleeding, or swelling", "Persistence or recurrence of skin tags", "Need for escalation to medical or procedural treatment", "Symptom severity score change over time", "Rate of complications if untreated" ] }, "category": "anorectal", "relatedConditions": [ "hemorrhoids", "anal-skin-tags", "anal-fissure" ], "relatedTreatments": [], "relatedEvidence": [], "bottomLine": { "verdict": "It's unclear — the few studies that looked at this directly don't agree with each other.", "detail": "Only two studies asked this exact question, and both only looked at one type: thrombosed external hemorrhoids (a painful blood clot in a hemorrhoid). One found that without surgery, symptoms often lasted more than three weeks. The other found about six in ten people said they felt healed or improved after six months without surgery. Neither study looked at internal hemorrhoids, bleeding, or skin tags left untreated, so this does not tell us what happens with those.", "studyIds": [ "pmid:23079956", "pmid:21694829" ] }, "strength": { "level": "very-low", "why": "The only direct evidence is 2 small or uncontrolled studies.", "override": null }, "direction": { "level": "unclear", "why": "The studies point in different directions.", "override": null }, "counts": { "recordsRetrieved": 295, "recordsScreened": 199, "included": 27, "rcts": 0, "systematicReviews": 3, "observational": 16, "participants": 11103, "yearFrom": 2009, "yearTo": 2026, "registeredTrialsWithoutResults": 0 }, "excluded": [], "outcomes": [ { "name": "Proportion that resolve without any treatment", "status": "insufficient", "note": "Only one study tracked this, and only in people with a thrombosed external hemorrhoid (a clot). About 63% said they were healed or improved six months later without surgery. No study has measured this for internal hemorrhoids or for skin tags.", "studyIds": [ "pmid:21694829" ] }, { "name": "Time to resolution of pain, bleeding, or swelling", "status": "insufficient", "note": "Reported times vary a lot between the small number of studies: one review found conservative care meant symptoms lasted over three weeks; a case series found pain mostly eased by 5 days and was gone by 10; another found an average of about 12 days. All of these are in people with a thrombosed external hemorrhoid, not hemorrhoids in general.", "studyIds": [ "pmid:23079956", "pmid:35064300", "pmid:30600960" ] }, { "name": "Persistence or recurrence of skin tags", "status": "not-studied", "note": "No study followed hemorrhoid skin tags over time to see whether they shrink, stay the same, or come back. One study in children found the lump sometimes stayed even after symptoms settled, but that was in children, not adults, and was about the hemorrhoid itself rather than a skin tag.", "studyIds": [ "pmid:40813828" ] }, { "name": "Need for escalation to medical or procedural treatment", "status": "insufficient", "note": "Some studies found only a minority of treated patients went on to need surgery, but every one of these patients was already receiving fiber, drugs, or other active treatment — none were left alone. So these numbers cannot tell us how many hemorrhoids would need treatment if nothing at all were done.", "studyIds": [ "pmid:28150480", "pmid:24606821" ] }, { "name": "Symptom severity score change over time", "status": "insufficient", "note": "Several studies measured symptom scores before and after a treatment such as fiber, phlebotonic drugs, or lidocaine, and scores improved. But none of these had an untreated comparison group, so the improvement cannot be separated from natural recovery that might have happened anyway.", "studyIds": [ "pmid:42205186", "pmid:42131632", "pmid:41299195", "pmid:39132755", "pmid:30276625", "pmid:30192331" ] }, { "name": "Rate of complications if left completely untreated", "status": "not-studied", "note": "No study followed a group of people with hemorrhoids who received no care at all and counted how often complications occurred. This remains unanswered.", "studyIds": [] } ], "benefits": [ { "text": "In people with a thrombosed external hemorrhoid (a painful clot), one study found about six in ten reported being healed or improved six months later without any surgery.", "studyIds": [ "pmid:21694829" ] }, { "text": "In case series of thrombosed external hemorrhoids treated with simple measures like sitz baths and pain medicine, pain mostly eased within about one to two weeks.", "studyIds": [ "pmid:35064300", "pmid:30600960" ] } ], "limitations": [ { "text": "Only two entries in this review look directly at what happens without surgery over time: a systematic review that pooled four smaller studies (819 patients total) and one small prospective cohort (72 patients). Neither compares conservative care with doing truly nothing — they describe symptom duration with conservative treatment or compare it against surgery — and both look only at a clotted external hemorrhoid, not hemorrhoids in general.", "studyIds": [ "pmid:23079956", "pmid:21694829" ] }, { "text": "Most other studies gave patients an active treatment (fiber, drugs, creams) and compared scores before and after. Without an untreated comparison group, there is no way to tell how much of the improvement would have happened anyway.", "studyIds": [ "pmid:42205186", "pmid:42131632", "pmid:41299195", "pmid:39132755", "pmid:30276625", "pmid:30192331", "pmid:28150480" ] }, { "text": "Much of the available data is retrospective, relies on patient self-report, or comes from narrow groups like pregnant women or the elderly, which may not reflect everyone.", "studyIds": [ "pmid:38698334", "pmid:38327723", "pmid:30600960" ] } ], "risks": [ { "text": "In studies of a thrombosed external hemorrhoid treated without surgery, how long pain and swelling took to settle varied a lot between studies: one found pain mostly gone by day 5 and fully gone by day 10, another found symptoms resolved after about 12 days on average, and a third reported symptoms lasting over 3 weeks. So real discomfort while waiting can last anywhere from about a week to several weeks.", "studyIds": [ "pmid:23079956", "pmid:30600960", "pmid:35064300" ], "severity": "minor" } ], "whyPeopleTryIt": [ { "text": "Embarrassment about discussing symptoms with a doctor" }, { "text": "Hoping mild symptoms are temporary and will pass on their own" }, { "text": "Wanting to avoid a procedure or surgery" }, { "text": "Past experience of a hemorrhoid flare settling down without treatment" }, { "text": "Cost or access barriers to seeing a doctor" } ], "keyStudies": [ "pmid:23079956", "pmid:21694829", "pmid:35064300", "pmid:30600960", "pmid:40813828", "pmid:38327723" ], "studies": [ { "id": "pmid:42205186", "pmid": "42205186", "doi": "10.3389/fsurg.2026.1771489", "nctId": null, "pmcid": "PMC13202786", "title": "Evaluating the effectiveness of oral phlebotonics for the conservative management of hemorrhoidal disease: insights from the VIVI2022/01/VIVALDI study", "firstAuthor": "Giani", "multipleAuthors": true, "journal": "Front Surg", "year": 2026, "design": "prospective-cohort", "n": 115, "nField": "reported", "population": "adults with symptomatic hemorrhoidal disease, grade I-II-III", "intervention": "oral phlebotonic drugs added to standard care", "comparator": "baseline (before treatment), no control group", "primaryOutcome": "change in hemorrhoidal disease symptom score", "result": "symptom score dropped substantially, bleeding and other measures also improved", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was an observational study with no comparison group, so improvement could be due to the condition improving on its own rather than the drug.", "directness": "indirect", "limitations": "no control or placebo group, so natural improvement cannot be distinguished from a drug effect; short 30-day follow-up", "followUp": "30 days", "plainFinding": "Symptoms improved over 30 days, but no comparison group.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42205186/", "sourceText": "BACKGROUND: The aim of this study is to describe the baseline characteristics of an Italian, real-world cohort of patients with symptomatic hemorrhoidal disease (HD) and to evaluate the effectiveness and safety of phlebotonic drugs, in addition to standard of care. METHODS: This is a prospective, multicenter, observational cohort study (VIVI2022/01/VIVALDI, ClinicalTrials.gov number: NCT07376928) on adults with symptomatic Goligher grade I-II-III HD. The primary endpoint was the improvement in the hemorrhoidal disease symptom score (HDSS). Secondary endpoints were based on the resolution of bleeding (Giamundo score), improvement in quality of life (Short Health Scale adapted for HD), Goligher grading, Single Pile Hemorrhoid Classification (SPHC), adverse events, satisfaction with treatment, and change in treatment strategy during the 30-day observational period. Patients were evaluated by visits and questionnaires at baseline and after 30 days; at day 30, the evaluation also included the assessment of surgical indication. At day 15, patients were also interviewed through a phone call in order to verify adherence and unexpected effects. RESULTS: A total of 115 patients (70% male), with a mean (SD) age of 51.4 years and HD diagnosed since an average of 4.6 (8.3) years, were enrolled. The mean HDSS decreased from 7.8 (3.6) at baseline to 3.7 (2.6) at day 30 (p < 0.001). Bleeding was reported by 94.8% of patients at baseline vs. 58.3% at day 30 (p < 0.0001). At day 30, 39.1% of patients displayed a Goligher downstaging. The mean SHS-HD score decreased from 11.29 (3.8) at baseline to 7.56 (2.8) at day 30 (p < 0.0001). The average number of piles per patient was 2.72 (1.6) at baseline and 2.51 (1.3) at day 30 [mean change: -0.32 (1.42); p = 0.0026]. Only one patient (<1%) reported one non-serious adverse event (moderate abdominal distension), which was deemed not related to the studied drug and did not lead to treatment discontinuation during the 30-day follow-up. Treatment was deemed satisfactory by 73% of patients, with none discontinuing within day 30. CONCLUSION: A 30-day course of conservative therapy with oral phlebotonics was found to be safe and effective in improving a variety of clinical measures in adults with symptomatic Goligher grade I-II-III HD.", "provenance": [ { "field": "population", "quote": "adults with symptomatic Goligher grade I-II-III HD" }, { "field": "intervention", "quote": "phlebotonic drugs, in addition to standard of care" }, { "field": "comparator", "quote": "baseline and after 30 days" }, { "field": "primaryOutcome", "quote": "The primary endpoint was the improvement in the hemorrhoidal disease symptom score (HDSS)." }, { "field": "result", "quote": "The mean HDSS decreased from 7.8 (3.6) at baseline to 3.7 (2.6) at day 30 (p < 0.001)." }, { "field": "n", "quote": "A total of 115 patients (70% male)" } ] }, { "id": "pmid:42131632", "pmid": "42131632", "doi": "10.7759/cureus.106860", "nctId": null, "pmcid": "PMC13161502", "title": "Beyond Symptom Relief: Quality of Life Recovery After Conservative Management of Early Hemorrhoids", "firstAuthor": "Agrawal", "multipleAuthors": true, "journal": "Cureus", "year": 2026, "design": "retrospective", "n": 50, "nField": "reported", "population": "adults with early-stage (Grade I or II) internal hemorrhoids", "intervention": "conservative management (non-surgical treatment)", "comparator": "patients' own symptom scores before treatment (baseline vs follow-up)", "primaryOutcome": "change in hemorrhoid symptom severity and quality of life", "result": "symptom severity score dropped substantially and physical and mental quality-of-life scores improved significantly after conservative treatment", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this is a small retrospective study with no comparison group and only six weeks of follow-up, so it cannot show what would have happened without treatment or over a longer time.", "directness": "indirect", "limitations": "retrospective design, no control or untreated comparison group, short minimum follow-up of six weeks, single center, relies on existing medical records", "followUp": "six weeks", "plainFinding": "Symptoms eased with conservative care.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/42131632/", "sourceText": "Introduction Hemorrhoidal disease is one of the most common anorectal disorders encountered in surgical practice and significantly affects patients' daily activities and well-being. Conservative management remains the first-line treatment for early hemorrhoids (Grade I and II), focusing primarily on symptom relief. However, the impact of conservative therapy on health-related quality of life has not been extensively evaluated. The present study aimed to assess symptomatic improvement and quality-of-life outcomes following conservative management in patients with early hemorrhoidal disease. Methods A retrospective observational study was conducted in the Department of General Surgery at ESIC Medical College and Hospital, Varanasi, India. Medical records of patients diagnosed with Grade I or Grade II internal hemorrhoids and managed conservatively were reviewed. Patients with a minimum follow-up duration of six weeks were included in the study. Symptom severity was assessed using the Hemorrhoid Severity Score (HSS). Health-related quality of life was evaluated using the Short Form-12 (SF-12) questionnaire, generating the Physical Component Score (PCS) and Mental Component Score (MCS). Baseline and follow-up scores were compared using paired statistical analysis. Subgroup analysis was performed to evaluate differences in improvement between Grade I and Grade II hemorrhoids. Results A total of 50 patients were included in the final analysis. The mean age of the study population was 45.04 ± 12.48 years, with equal gender distribution comprising 25 (50%) males and 25 (50%) females. Grade II hemorrhoids were present in 29 (58%) patients, while 21 (42%) had Grade I disease. Following conservative management, a significant reduction in symptom severity was observed. The mean Hemorrhoid Severity Score decreased from 10.71 ± 2.01 at baseline to 5.57 ± 2.39 at follow-up (p < 0.001), indicating substantial improvement. Similarly, the mean Physical Component Score improved from 39.31 ± 2.78 to 49.18 ± 3.26 (p < 0.001), reflecting better physical functioning, while the mean Mental Component Score improved from 40.99 ± 2.79 to 49.51 ± 3.72 (p < 0.001), indicating enhanced psychological well-being. Large effect sizes were observed for improvements in symptom severity and quality-of-life measures. Subgroup analysis demonstrated comparable improvement between Grade I and Grade II hemorrhoids. Additionally, no significant correlation was identified between the magnitude of symptom improvement and changes in quality-of-life scores. Conclusion Conservative management of Grade I and II hemorrhoids leads to significant reduction in symptom severity and substantial improvement in both physical and mental aspects of quality of life. These findings reinforce the role of conservative therapy as an effective first-line treatment strategy in early hemorrhoidal disease.", "provenance": [ { "field": "n", "quote": "A total of 50 patients were included in the final analysis." }, { "field": "population", "quote": "patients diagnosed with Grade I or Grade II internal hemorrhoids and managed conservatively" }, { "field": "intervention", "quote": "Conservative management remains the first-line treatment for early hemorrhoids (Grade I and II)" }, { "field": "comparator", "quote": "Baseline and follow-up scores were compared using paired statistical analysis." }, { "field": "primaryOutcome", "quote": "Symptom severity was assessed using the Hemorrhoid Severity Score (HSS). Health-related quality of life was evaluated using the Short Form-12 (SF-12) questionnaire" }, { "field": "result", "quote": "The mean Hemorrhoid Severity Score decreased from 10.71 ± 2.01 at baseline to 5.57 ± 2.39 at follow-up (p < 0.001)" }, { "field": "followUp", "quote": "Patients with a minimum follow-up duration of six weeks were included in the study." } ] }, { "id": "pmid:41837899", "pmid": "41837899", "doi": "10.1097/MCG.0000000000002360", "nctId": null, "pmcid": null, "title": "Comparative Effectiveness of Lidocaine- Versus Nifedipine-Based Multimodal Conservative Regimens for Acute Hemorrhoidal Disease: A Multicenter Cohort Study", "firstAuthor": "Schiano di Visconte", "multipleAuthors": true, "journal": "J Clin Gastroenterol", "year": 2026, "design": "retrospective", "n": 266, "nField": "reported", "population": "patients with acute hemorrhoidal disease (Goligher grades I to III or thrombosed external hemorrhoids)", "intervention": "multimodal conservative therapy with phlebotonics, bromelain, and topical lidocaine (or nifedipine)", "comparator": "conventional conservative therapy", "primaryOutcome": "changes in hemorrhoid symptom score and pain (VAS) scores", "result": "lidocaine-based regimen gave earlier and greater reduction in pain and symptoms, with less need for rescue pain medicine, compared with standard care and nifedipine regimen", "resultDirection": "benefit", "quality": "low", "qualityWhy": "it's a retrospective, non-randomized comparison across centers, so differences could be due to other factors rather than the treatment itself.", "directness": "indirect", "limitations": "retrospective design, not randomized, no information on natural resolution without any treatment", "followUp": "not reported beyond 'within the first 14 days of treatment'", "plainFinding": "Lidocaine mix eased symptoms faster.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41837899/", "sourceText": "BACKGROUND: Hemorrhoidal disease (HD) significantly impairs quality of life, and existing conservative treatments often yield delayed or insufficient relief. This multicentre cohort study evaluated the comparative effectiveness of structured multimodal conservative regimens versus standard conservative care in patients with acute hemorrhoidal disease (AHD). METHODS: This retrospective cohort study, conducted across 5 Italian proctology centres, included 266 patients with AHD (Goligher grades I to III or thrombosed external hemorrhoids) treated between November 2024 and June 2025. Patients were assigned to 3 groups: group A (n=90) received a multimodal approach with phlebotonics, bromelain, and topical lidocaine; group C (n=93) received the same oral regimen with topical nifedipine; and group B (n=83) received conventional conservative therapy. Primary outcomes were changes in the Hemorrhoidal Disease Symptom Score (HDSS) and the visual analog scale (VAS) for pain. RESULTS: While all treatment strategies yielded significant symptom improvement over time, the lidocaine-based multimodal regimen (group A) was associated with earlier and more pronounced reductions in pain, symptom burden, and impairment in health-related quality of life (SHS-HD), particularly within the first 14 days of treatment (P<0.001 for all comparisons). Patients treated with the lidocaine-based regimen required less rescue systemic analgesia (8.9% vs. 28.9% in group B and 26.9% in group C; P<0.001) and underwent fewer urgent procedural interventions than those receiving standard care. Early resolution of bleeding and perianal oedema was also more frequent in the multimodal arms. CONCLUSION: In this multicentre retrospective cohort study, structured multimodal conservative therapy, particularly the lidocaine-based regimen, was associated with faster symptom relief, improved patient-reported quality of life, and a reduced need for urgent procedures compared with standard conservative care for AHD. These findings suggest the need for further prospective evaluation of lidocaine-centred multimodal protocols in the conservative management of AHD.", "provenance": [ { "field": "design", "quote": "This retrospective cohort study, conducted across 5 Italian proctology centres, included 266 patients with AHD" }, { "field": "n", "quote": "included 266 patients with AHD (Goligher grades I to III or thrombosed external hemorrhoids) treated between November 2024 and June 2025" }, { "field": "population", "quote": "patients with AHD (Goligher grades I to III or thrombosed external hemorrhoids)" }, { "field": "intervention", "quote": "group A (n=90) received a multimodal approach with phlebotonics, bromelain, and topical lidocaine; group C (n=93) received the same oral regimen with topical nifedipine" }, { "field": "comparator", "quote": "group B (n=83) received conventional conservative therapy" }, { "field": "primaryOutcome", "quote": "Primary outcomes were changes in the Hemorrhoidal Disease Symptom Score (HDSS) and the visual analog scale (VAS) for pain." }, { "field": "result", "quote": "the lidocaine-based multimodal regimen (group A) was associated with earlier and more pronounced reductions in pain, symptom burden, and impairment in health-related quality of life (SHS-HD), particularly within the first 14 days of treatment (P<0.001 for all comparisons)." } ] }, { "id": "pmid:41299195", "pmid": "41299195", "doi": "10.1177/03000605251397889", "nctId": null, "pmcid": "PMC12907802", "title": "The aCute HemORrhoidal disease evALuation International Study (CHORALIS): Subanalysis of the effectiveness of conservative treatment during the acute phase of hemorrhoidal disease in Vietnam", "firstAuthor": "Tin", "multipleAuthors": true, "journal": "J Int Med Res", "year": 2025, "design": "prospective-cohort", "n": 202, "nField": "reported", "population": "adults with acute hemorrhoidal disease (within 48 hours of onset) in Vietnam", "intervention": "conservative treatment, mainly micronized purified flavonoid fraction-based therapy", "comparator": "no control group; symptoms compared to baseline before treatment", "primaryOutcome": "change in hemorrhoid symptoms and quality of life over four weeks", "result": "average number of symptoms dropped from 4.6 to 1.0 by week four, with high patient and physician satisfaction", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was an observational study without a comparison group, so it cannot show whether symptoms would have improved without treatment.", "directness": "indirect", "limitations": "no untreated control group, so natural improvement cannot be separated from treatment effect; observational design", "followUp": "week four", "plainFinding": "Symptoms improved with flavonoid treatment.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/41299195/", "sourceText": "BackgroundAlthough hemorrhoidal disease is common worldwide, real-world evidence on the effectiveness of conservative treatments during the acute phase remains limited.ObjectiveWe aimed to assess the effectiveness of conservative treatment in improving symptoms and quality of life in patients with acute hemorrhoids in Vietnam.Patients and methodsThis was a prospective, international, observational, longitudinal study based on a subanalysis of the aCute HemORrhoidal disease evALuation International Study conducted from January 2022 to June 2022 at five major hospitals in Vietnam. The present study included adult patients (≥18 years) diagnosed with acute hemorrhoidal disease (≤48 h since onset) who received conservative treatment and did not require surgical intervention.ResultsAmong the 202 patients, 53% were male; the mean population age was 40.5 ± 13.7 years, and the mean body mass index was 22.13 ± 2.59 kg/m2. The distribution of hemorrhoid severity was as follows: grade I, 22.3%; grade II, 59.9%; grade III, 12.4%; and grade IV, 5.4%. The mean number of symptoms per patient decreased from 4.6 ± 1.9 at baseline to 1.0 ± 1.5 at week four. At week one, the venoactive drug group showed symptom improvement rates of 63% for pain, 56.8% for discomfort, and 68.2% for bleeding. The Hemorrhoid and Fissure Quality of Life significantly decreased across all domains (p < 0.05). Patient and physician satisfaction with conservative treatment was high, at 88.7% and 87.7%, respectively.ConclusionConservative treatment, particularly micronized purified flavonoid fraction-based therapy, improved the clinical symptoms and quality of life in patients with acute hemorrhoids in Vietnam.", "provenance": [ { "field": "population", "quote": "adult patients (≥18 years) diagnosed with acute hemorrhoidal disease (≤48 h since onset) who received conservative treatment and did not require surgical intervention" }, { "field": "intervention", "quote": "Conservative treatment, particularly micronized purified flavonoid fraction-based therapy" }, { "field": "comparator", "quote": "The mean number of symptoms per patient decreased from 4.6 ± 1.9 at baseline to 1.0 ± 1.5 at week four" }, { "field": "primaryOutcome", "quote": "assess the effectiveness of conservative treatment in improving symptoms and quality of life in patients with acute hemorrhoids" }, { "field": "result", "quote": "The mean number of symptoms per patient decreased from 4.6 ± 1.9 at baseline to 1.0 ± 1.5 at week four." }, { "field": "n", "quote": "Among the 202 patients, 53% were male" } ] }, { "id": "pmid:40824576", "pmid": "40824576", "doi": "10.1001/jama.2025.13083", "nctId": null, "pmcid": null, "title": "Hemorrhoidal Disease: A Review", "firstAuthor": "Ashburn", "multipleAuthors": false, "journal": "JAMA", "year": 2025, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with hemorrhoidal disease (internal, external, or mixed)", "intervention": "various treatments including dietary fiber/water intake, phlebotonics, rubber band ligation, sclerotherapy, infrared coagulation, and surgery", "comparator": "", "primaryOutcome": "", "result": "The abstract reports treatment-related outcomes (for example, symptom recurrence after phlebotonics and success rates for various procedures) but does not report what happens if hemorrhoids are left untreated or how long spontaneous resolution takes.", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a narrative review summarizing treatment outcomes, not a study of untreated or spontaneous resolution, so it cannot answer whether or how fast hemorrhoids resolve on their own.", "directness": "indirect", "limitations": "The abstract does not report any data on natural history or spontaneous resolution without treatment; it focuses entirely on the effects of medical and procedural interventions.", "followUp": "", "plainFinding": "Doesn't address spontaneous resolution.", "retracted": false, "expressionOfConcern": false, "hasErratum": true, "url": "https://pubmed.ncbi.nlm.nih.gov/40824576/", "sourceText": "IMPORTANCE: Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US. Hemorrhoidal disease may impair quality of life due to bleeding, pain, anal irritation, and tissue prolapse. OBSERVATIONS: Hemorrhoids are classified as internal, external, or mixed (concurrent internal and external hemorrhoidal disease). Internal hemorrhoids originate above the dentate line, the boundary between the upper and lower anal canal, and may cause rectal bleeding, discomfort, and tissue prolapse from the anal canal. Internal hemorrhoid prolapse is classified as grade I (into anal canal), grade II (beyond the anus with spontaneous reduction), grade III (requiring manual reduction), and grade IV (irreducible). External hemorrhoids, arising below the dentate line, cause rectal pain when engorged or thrombosed. Initial treatment of all hemorrhoidal disease involves increasing intake of dietary fiber and water and avoiding straining during defecation. Phlebotonics (eg, flavonoids [thought to improve venous tone]) reduce bleeding, rectal pain, and swelling, although symptom recurrence reaches 80% within 3 to 6 months after treatment cessation. If dietary modification and phlebotonics are ineffective, grade I to grade III internal hemorrhoidal disease can be treated with office-based interventions. Rubber band ligation-placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow-resolves symptoms in 89% of patients, but repeated banding is needed in up to 20%. Sclerotherapy, which induces fibrosis with a sclerosant injection, is efficacious in the short term (weeks to months) among 70% to 85% of patients, but long-term remission occurs in only one-third of patients. Infrared coagulation uses heat to coagulate hemorrhoidal tissue, yielding 70% to 80% success in reducing bleeding and prolapse. Excisional hemorrhoidectomy, for disease unresponsive to office-based therapy or for mixed hemorrhoidal disease, achieves low recurrence (2%-10%), although with longer recovery (9-14 days). External hemorrhoidal disease rarely requires surgery unless acutely thrombosed. Outpatient clot evacuation within 72 hours of onset of a thrombosed external hemorrhoid is associated with decreased pain and reduced risk of repeat thrombosis. Patients presenting more than 72 hours after external hemorrhoid acute thrombosis should receive medical treatment (eg, stool softeners, oral and topical analgesics such as 5% lidocaine). CONCLUSIONS AND RELEVANCE: Hemorrhoidal disease affects 10 million people in the US. First-line treatment is increased fiber intake, avoidance of straining during defecation, and phlebotonics. In-office rubber band ligation for grade I to III internal hemorrhoid disease is first-line procedural treatment for persistent symptoms despite conservative therapies. Excisional hemorrhoidectomy is recommended for grade III to IV prolapse, thrombosis, or mixed hemorrhoidal disease that does not improve with less invasive approaches.", "provenance": [ { "field": "population", "quote": "Hemorrhoidal disease, pathology of the tissue lining of the anal canal, affects approximately 10 million individuals in the US." }, { "field": "intervention", "quote": "Initial treatment of all hemorrhoidal disease involves increasing intake of dietary fiber and water and avoiding straining during defecation." }, { "field": "intervention", "quote": "Phlebotonics (eg, flavonoids [thought to improve venous tone]) reduce bleeding, rectal pain, and swelling" }, { "field": "intervention", "quote": "Rubber band ligation-placing a band around the base of hemorrhoid tissue during anoscopy to restrict blood flow-resolves symptoms in 89% of patients" }, { "field": "result", "quote": "symptom recurrence reaches 80% within 3 to 6 months after treatment cessation" } ] }, { "id": "pmid:40813828", "pmid": "40813828", "doi": "10.1007/s00431-025-06392-2", "nctId": null, "pmcid": "PMC12354542", "title": "Pediatric external hemorrhoids: clinical characteristics and outcomes of conservative treatment versus injection sclerotherapy", "firstAuthor": "Docter", "multipleAuthors": true, "journal": "Eur J Pediatr", "year": 2025, "design": "retrospective", "n": 44, "nField": "reported", "population": "children with external hemorrhoids at a pediatric hospital", "intervention": "conservative management (watchful waiting)", "comparator": "injection sclerotherapy", "primaryOutcome": "resolution of symptoms and the hemorrhoid lesion", "result": "with watchful waiting, symptoms went away within a year but the hemorrhoid lump itself often stayed", "resultDirection": "mixed", "quality": "low", "qualityWhy": "this is a small retrospective chart review of children without randomization, so it can't reliably prove how long hemorrhoids take to resolve in general.", "directness": "indirect", "limitations": "retrospective design, small sample, diagnosis often based on parent photographs rather than direct examination, population is children not adults", "followUp": "within one year", "plainFinding": "Symptoms eased in a year, lump stayed.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40813828/", "sourceText": "UNLABELLED: Pediatric external hemorrhoids are rare and often misdiagnosed. This study assesses clinical presentation, risk factors, and treatment outcomes, comparing conservative management with injection sclerotherapy. A retrospective cohort study (2007-2024) was conducted at a tertiary pediatric hospital, including pediatric patients treated with conservative therapy (watchful waiting) or injection sclerotherapy for external hemorrhoids. Data from medical records were analyzed for patient history, presentation, treatment outcomes, and complications. Forty-four patients (86.4% male) were included. Mean age at symptom onset and presentation was respectively 4.0 (range 0-11) and 5.8 (range 2-13) years, with a median diagnostic delay of 20.5 months. All reported anal protrusion/swelling during/after defecation, though this was only visible on examination in 11.4%; diagnosis was otherwise based on parent-provided photographs (63.6%) or reference images (25.0%). Additional symptoms included pain (45.5%), bleeding (18.2%), anal itching (13.6%), anxiety (9.1%) and tenesmus (6.8%). Thirty-one patients (70.5%) underwent injection sclerotherapy, with a 69.2% success rate after one, and 90.3% after two injections. Thirteen patients (29.5%) were treated conservatively with watchful waiting, with symptoms resolving within one year, although the lesion(s) persisted. Skin erosion occurred in 35.5% of patients treated with injection sclerotherapy, leading to constipation and defecation anxiety in 9.1% of patients. CONCLUSION: Pediatric external hemorrhoids present as anal protrusion/swelling, often accompanied by anorectal pain. Diagnosis is often delayed due to its intermittent nature. Parent-provided photographs can confirm diagnosis. Both conservative management and injection sclerotherapy are viable treatments; injection sclerotherapy offers a definitive resolution but carries risks of relapse and complications. WHAT IS KNOWN: • Pediatric external hemorrhoids are often misdiagnosed and mismanaged. WHAT IS NEW: • Due to the intermittent nature of external hemorrhoids, diagnosis is often delayed, making parent-provided photographs highly valuable for accurate assessment. • Both conservative management and injection sclerotherapy are viable treatments. • Injection sclerotherapy carries risks of relapse and complications.", "provenance": [ { "field": "n", "quote": "Forty-four patients (86.4% male) were included." }, { "field": "population", "quote": "Pediatric external hemorrhoids are rare and often misdiagnosed." }, { "field": "intervention", "quote": "conservative therapy (watchful waiting)" }, { "field": "comparator", "quote": "injection sclerotherapy" }, { "field": "primaryOutcome", "quote": "treatment outcomes, and complications" }, { "field": "result", "quote": "Thirteen patients (29.5%) were treated conservatively with watchful waiting, with symptoms resolving within one year, although the lesion(s) persisted." } ] }, { "id": "pmid:40740911", "pmid": "40740911", "doi": "10.4240/wjgs.v17.i7.107099", "nctId": null, "pmcid": "PMC12305257", "title": "TONEFACT: Can even advanced hemorrhoids be treated without surgery? A paradigm shift in the management of hemorrhoids", "firstAuthor": "Garg", "multipleAuthors": true, "journal": "World J Gastrointest Surg", "year": 2025, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with early to advanced hemorrhoids", "intervention": "conservative management treatment concept called TONEFACT", "comparator": "surgery", "primaryOutcome": "defecation time, prolapse symptoms, and need for surgery", "result": "improved defecation time and reduced prolapse symptoms, with fewer surgeries needed", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is an opinion review based mainly on the authors' own experience and observational studies, not controlled trials.", "directness": "indirect", "limitations": "Evidence comes mainly from observational studies and one small non-randomized study; the abstract states findings lack validation from larger randomized controlled trials.", "followUp": "", "plainFinding": "Conservative care may avoid surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40740911/", "sourceText": "Hemorrhoids are one of the most common anorectal disorders. Early hemorrhoids are treated conservatively, but advanced hemorrhoids are usually treated with surgery. However, in the last decade, we have worked extensively in the field of conservative management of hemorrhoids. From our experience, we could manage a large proportion of advanced hemorrhoids without surgery by a treatment concept (TONEFACT) with a high satisfaction rate. Evidence for the TONEFACT approach primarily comes from observational studies and a prospective, non-randomized study of 85 patients. This has been shown to improve defecation time and reduce prolapse symptoms in early-stage hemorrhoids, leading to fewer surgical interventions. Although promising, these observations lack validation from more extensive randomized controlled trials to draw firm conclusions. In this opinion review, without using much data, we will discuss our viewpoint based on our experience as specified by the journal guidelines.", "provenance": [ { "field": "population", "quote": "advanced hemorrhoids" }, { "field": "intervention", "quote": "a treatment concept (TONEFACT)" }, { "field": "comparator", "quote": "usually treated with surgery" }, { "field": "primaryOutcome", "quote": "improve defecation time and reduce prolapse symptoms in early-stage hemorrhoids, leading to fewer surgical interventions" }, { "field": "result", "quote": "This has been shown to improve defecation time and reduce prolapse symptoms in early-stage hemorrhoids, leading to fewer surgical interventions." }, { "field": "limitations", "quote": "Evidence for the TONEFACT approach primarily comes from observational studies and a prospective, non-randomized study of 85 patients." }, { "field": "limitations", "quote": "Although promising, these observations lack validation from more extensive randomized controlled trials to draw firm conclusions." } ] }, { "id": "pmid:40596934", "pmid": "40596934", "doi": "10.1186/s12876-025-04089-2", "nctId": null, "pmcid": "PMC12211330", "title": "Comparison of efficacy and safety between surgical and conservative treatments for hemorrhoids: a meta-analysis", "firstAuthor": "Quan", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2025, "design": "meta-analysis", "n": 760, "nField": "reported", "population": "people with hemorrhoids, including pregnant women with thrombosed external hemorrhoids", "intervention": "surgical treatment for hemorrhoids", "comparator": "non-invasive conservative treatment for hemorrhoids", "primaryOutcome": "complete symptom resolution and pain scores after treatment", "result": "Surgery had higher rates of full symptom resolution and better pain relief within four days, but pain scores were equal to conservative treatment after ten days; surgery also sped recovery and lowered recurrence, with similar rates of bleeding and urinary retention.", "resultDirection": "mixed", "quality": "low", "qualityWhy": "It pools only seven small studies (760 patients total) comparing active treatments, with some heterogeneity in results, so it says little about hemorrhoids resolving without any treatment.", "directness": "indirect", "limitations": "The abstract does not describe limitations such as study quality, blinding, or risk of bias explicitly.", "followUp": "", "plainFinding": "Faster relief with surgery; equal by 10 days.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40596934/", "sourceText": "OBJECTIVES: Hemorrhoids, a common anorectal condition, can be managed through surgical or conservative treatments. The aim of this meta-analysis is to compare the efficacy and safety of surgical and conservative treatments for hemorrhoids. METHODS: A systematic search was conducted from of PubMed, Embase, the Cochrane Library, and Web of Science from their inception to September 25, 2024. Eligible studies compared surgical treatments with non-invasive conservative treatments in hemorrhoids. Statistical analyses included pooled odds ratios (ORs) and mean differences (MDs)/standard mean differences (SMDs) with 95% confidence intervals (CIs). RESULTS: Seven studies, including 760 patients, were analyzed. Surgery achieved higher rates of complete symptom resolution than conservative therapy (OR = 2.96, 95% CI: 1.66-5.28, p < 0.001). Overall pain scores favored surgery (SMD = -0.93, 95% CI: 1.73 to -0.13, p = 0.02). Subgroup analysis showed clear superiority within four days (SMD = -1.26, 95% CI -1.84 to -0.68) but parity beyond ten days (SMD = 0.00, 95% CI -0.44 to 0.44; p = 0.99). Comparable patterns were observed in pregnant women with thrombosed external hemorrhoids. Rates of postoperative bleeding (OR: 1.09; 95% CI: 0.42 to 2.82, p = 0.86; I2 = 41%, p = 0.15) and urinary retention (OR: 1.75; 95% CI: 0.30 to 10.31, p = 0.54; I2 = 45%, p = 0.18) did not differ significantly between groups. Surgical-specific adverse events were infrequent (incontinence 3%, persistent pain 5%, watery discharge 6%). Surgery shortened recovery in pregnant thrombosed cases by approximately seven days (MD: -6.80; 95% CI: -7.64 to -5.96, p < 0.001; I2 = 55%, p = 0.14) and reduced overall recurrence (95% CI: 0.10 to 0.37, p < 0.001; I2 = 0%, p = 0.97). CONCLUSION: Surgical treatments provide superior symptom relief, faster recovery, and lower recurrence but with some specific post-treatment complications, while conservative treatments are safer and less invasive but with provides slower symptom relief and higher recurrence rates. Individualized treatment should consider symptom severity, patient preferences, and risk tolerance.", "provenance": [ { "field": "n", "quote": "Seven studies, including 760 patients, were analyzed." }, { "field": "population", "quote": "Comparable patterns were observed in pregnant women with thrombosed external hemorrhoids." }, { "field": "intervention", "quote": "Eligible studies compared surgical treatments with non-invasive conservative treatments in hemorrhoids." }, { "field": "comparator", "quote": "Eligible studies compared surgical treatments with non-invasive conservative treatments in hemorrhoids." }, { "field": "primaryOutcome", "quote": "Surgery achieved higher rates of complete symptom resolution than conservative therapy (OR = 2.96, 95% CI: 1.66-5.28, p < 0.001)." }, { "field": "result", "quote": "Subgroup analysis showed clear superiority within four days (SMD = -1.26, 95% CI -1.84 to -0.68) but parity beyond ten days (SMD = 0.00, 95% CI -0.44 to 0.44; p = 0.99)." } ] }, { "id": "pmid:40581544", "pmid": "40581544", "doi": "10.1016/j.surge.2025.06.002", "nctId": null, "pmcid": null, "title": "Comparative efficacy of lidocaine- and nifedipine-based conservative therapies in acute hemorrhoidal disease: A retrospective cohort study", "firstAuthor": "Schiano di Visconte", "multipleAuthors": false, "journal": "Surgeon", "year": 2025, "design": "retrospective", "n": 123, "nField": "reported", "population": "patients with acute hemorrhoidal disease", "intervention": "oral diosmin/hesperidin, bromelain, and topical lidocaine", "comparator": "oral diosmin/hesperidin, bromelain, and topical nifedipine", "primaryOutcome": "symptom relief measured by pain scale, hemorrhoid symptom score, and health scale at days 7, 14, 21", "result": "lidocaine-based treatment gave faster pain relief and symptom improvement than nifedipine-based treatment by day 7", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a retrospective study comparing two treatments without a placebo or untreated group, so it cannot show whether hemorrhoids would have improved on their own.", "directness": "indirect", "limitations": "Retrospective design; no untreated/placebo comparison group; single center.", "followUp": "21 days", "plainFinding": "Faster symptom relief with lidocaine combo.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40581544/", "sourceText": "BACKGROUND: Acute hemorrhoidal disease (AHD) is a prevalent anorectal condition that significantly impacts patients' quality of life and healthcare systems. Despite the availability of various conservative treatments, comparative efficacy data remains limited. This retrospective study evaluates two treatment regimens for AHD, focusing on symptom relief, patient-reported outcomes, and treatment tolerability. METHODS: Medical records of 123 patients with AHD treated at a tertiary care center between October 2022 and October 2024 were reviewed. Patients were divided into two groups: Group A treated with oral diosmin/hesperidin, bromelain, and topical lidocaine, and Group B treated with oral diosmin/hesperidin, bromelain, and topical nifedipine. Symptoms were evaluated using the Hemorrhoidal Disease Symptom Score (HDSS), Visual Analog Scale (VAS) for pain, and Short Health Scale for Hemorrhoidal Disease (SHS-HD) at baseline and on days 7, 14, and 21. RESULTS: Both groups showed significant improvements in symptoms during the study period. Group A demonstrated faster pain reduction (VAS day 7:0.17 ± 0.52 vs. 2.20 ± 1.11, p < 0.001) and greater improvement in HDSS score (day 7: 0.02 ± 0.87 vs. 10.16 ± 3.38, p < 0.001). Improvements in SHS-HD scores were more rapid for Group A, with scores on day 7 showing a significant difference (Group A: 7.58 ± 2.58 vs. Group B: 12.27 ± 4.21, p < 0.001). Both regimens were well tolerated, with no significant adverse events. CONCLUSIONS: The combination of oral diosmin/hesperidin, bromelain, and lidocaine provides superior initial symptom relief compared with nifedipine-based regimens. Lidocaine is the preferred topical agent for rapid pain management in AHD patients. Further studies are required to confirm these results.", "provenance": [ { "field": "n", "quote": "Medical records of 123 patients with AHD treated at a tertiary care center between October 2022 and October 2024 were reviewed." }, { "field": "population", "quote": "patients with AHD treated at a tertiary care center" }, { "field": "intervention", "quote": "Group A treated with oral diosmin/hesperidin, bromelain, and topical lidocaine" }, { "field": "comparator", "quote": "Group B treated with oral diosmin/hesperidin, bromelain, and topical nifedipine" }, { "field": "primaryOutcome", "quote": "Symptoms were evaluated using the Hemorrhoidal Disease Symptom Score (HDSS), Visual Analog Scale (VAS) for pain, and Short Health Scale for Hemorrhoidal Disease (SHS-HD) at baseline and on days 7, 14, and 21." }, { "field": "result", "quote": "Group A demonstrated faster pain reduction (VAS day 7:0.17 ± 0.52 vs. 2.20 ± 1.11, p < 0.001) and greater improvement in HDSS score (day 7: 0.02 ± 0.87 vs. 10.16 ± 3.38, p < 0.001)." } ] }, { "id": "pmid:40576944", "pmid": "40576944", "doi": "10.1007/s13304-025-02302-1", "nctId": null, "pmcid": null, "title": "Operative versus nonoperative treatment of thrombosed external hemorrhoids: a systematic review and meta-analysis", "firstAuthor": "Martins", "multipleAuthors": true, "journal": "Updates Surg", "year": 2026, "design": "meta-analysis", "n": 851, "nField": "reported", "population": "people with thrombosed external hemorrhoids", "intervention": "surgical treatment", "comparator": "conservative (nonsurgical) treatment", "primaryOutcome": "risk of hemorrhoid recurrence and bleeding", "result": "surgery had lower recurrence risk but no difference in bleeding risk compared with conservative treatment", "resultDirection": "mixed", "quality": "moderate", "qualityWhy": "it pools six studies with moderate-to-high statistical heterogeneity, so the combined estimates are only moderately reliable", "directness": "indirect", "limitations": "abstract reports heterogeneity (I2 up to 60%) and does not describe study quality, blinding, or whether included studies were randomized", "followUp": "", "plainFinding": "Surgery cut recurrence, not bleeding risk", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/40576944/", "sourceText": "Thrombosed external hemorrhoids are a complication of hemorrhoids characterized by severe pain, swelling, and lump formation due to acute venous engorgement. Treatment options remain controversial, with limited evidence guiding the choice between surgical and conservative approaches. PubMed, Embase, and Cochrane Library databases were searched from inception to December 2024 to identify clinical trials comparing surgery with conservative treatment in thrombosed external hemorrhoids. Statistical analyses were performed using Review Manager 5.4.1 with a random-effects model. Heterogeneity was assessed using the I2 test. We included six studies with a total of 851 patients, of whom 390 (45.8%) underwent surgical treatment. Surgical treatment was associated with a lower risk of recurrence compared to conservative management (RR 0.49; 95% CI 0.26-0.91; P < 0.05; I2 = 54%). However, there were no significant differences in the risk of bleeding between the groups (RR 0.96; 95% CI 0.27-3.44; P = 0.95; I2 = 60%). Subgroup analyses of the excision surgery group revealed no differences between approaches. Our main findings indicated no significant difference in bleeding between surgery and conservative treatment groups. However, operative management is associated with significantly lower recurrences, which should be the preferred choice.", "provenance": [ { "field": "population", "quote": "Thrombosed external hemorrhoids are a complication of hemorrhoids characterized by severe pain, swelling, and lump formation due to acute venous engorgement." }, { "field": "intervention", "quote": "surgical treatment" }, { "field": "comparator", "quote": "conservative management" }, { "field": "n", "quote": "We included six studies with a total of 851 patients, of whom 390 (45.8%) underwent surgical treatment." }, { "field": "primaryOutcome", "quote": "Surgical treatment was associated with a lower risk of recurrence compared to conservative management" }, { "field": "result", "quote": "Surgical treatment was associated with a lower risk of recurrence compared to conservative management (RR 0.49; 95% CI 0.26-0.91; P < 0.05; I2 = 54%). However, there were no significant differences in the risk of bleeding between the groups (RR 0.96; 95% CI 0.27-3.44; P = 0.95; I2 = 60%)." } ] }, { "id": "pmid:39132755", "pmid": "39132755", "doi": "10.57264/cer-2024-0070", "nctId": null, "pmcid": "PMC11426285", "title": "An international observational study assessing conservative management in hemorrhoidal disease: results of CHORALIS (aCute HemORrhoidal disease evALuation International Study)", "firstAuthor": "Godeberge", "multipleAuthors": true, "journal": "J Comp Eff Res", "year": 2024, "design": "prospective-cohort", "n": 3505, "nField": "reported", "population": "adult outpatients with hemorrhoid symptoms seeking care", "intervention": "conservative treatments, mainly venoactive drugs (VADs) such as micronized purified flavonoid fraction (MPFF) and diosmin", "comparator": "diosmin (another venoactive drug) compared with MPFF", "primaryOutcome": "improvement in hemorrhoid signs/symptoms and quality of life", "result": "Both drug types improved symptoms and quality of life, with MPFF showing faster and greater improvement than diosmin", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was an observational study with no untreated or placebo group, so it cannot show whether hemorrhoids would have improved without treatment.", "directness": "indirect", "limitations": "No untreated or placebo comparison group; observational design; patient-reported outcomes; most patients received active drug treatment, so natural course of disease is not assessed.", "followUp": "4-week", "plainFinding": "No evidence on natural resolution", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/39132755/", "sourceText": "Aim: Real-world evidence on the management of hemorrhoidal disease (HD) is limited. This international study collected clinical practice data on the effectiveness of conservative treatments for acute HD on symptoms and quality of life (QoL), providing perspectives of treatment modalities from different continents. Patients & methods: The 4-week observational prospective CHORALIS study involved adult outpatients consulting for spontaneous complaints of hemorrhoids (graded using Goligher classification) and prescribed conservative treatments according to usual clinical practice. Assessments were: anal pain/discomfort (visual analog scale [VAS]), other signs/symptoms (patient questionnaire), Patient Global Impression of Change (PGI-C) questionnaire and disease-specific QoL (HEMO-FISS-QoL questionnaire). Results: Of 3592 participants, 3505 were analyzed (58.4% male; age 40.5 ± 13.7 years; history of HD in 48.4%; 72.1% Goligher grade I and II). Pain and discomfort were the most common symptoms. Most treatments were venoactive drugs (VADs; 90.9%), particularly micronized purified flavonoid fraction (MPFF; 73.7%) and diosmin (14.6%). All VAD-based therapies improved signs/symptoms (number/intensity/frequency of pain, discomfort, bleeding, swelling, itching and soiling) and QoL. MPFF was associated with a significantly greater proportion of patients with no symptoms (48.8 vs diosmin 34.4%, p < 0.001), pain disappearance (69.7 vs diosmin 52.8%, p < 0.001), treatment impact at 1 week rated on PGI-C as 'very much better' (30.5 vs diosmin 17.9%, p < 0.001) and shorter times to improvement (mean ± SD 3.9 ± 1.5 days vs diosmin 4.2 ± 1.7 days). Conclusion: In this prospective real-world study of patients with acute HD, conservative therapies consisting mainly of VADs, including MPFF, improved the clinical signs and symptoms of disease, as well as QoL. This study evidence supports clinical advantages associated with VADs, mostly MPFF, for effectively managing acute HD.", "provenance": [ { "field": "n", "quote": "3505 were analyzed" }, { "field": "population", "quote": "adult outpatients consulting for spontaneous complaints of hemorrhoids (graded using Goligher classification)" }, { "field": "intervention", "quote": "Most treatments were venoactive drugs (VADs; 90.9%), particularly micronized purified flavonoid fraction (MPFF; 73.7%) and diosmin (14.6%)" }, { "field": "comparator", "quote": "MPFF was associated with a significantly greater proportion of patients with no symptoms (48.8 vs diosmin 34.4%, p < 0.001)" }, { "field": "primaryOutcome", "quote": "All VAD-based therapies improved signs/symptoms (number/intensity/frequency of pain, discomfort, bleeding, swelling, itching and soiling) and QoL" }, { "field": "result", "quote": "MPFF was associated with a significantly greater proportion of patients with no symptoms (48.8 vs diosmin 34.4%, p < 0.001), pain disappearance (69.7 vs diosmin 52.8%, p < 0.001), treatment impact at 1 week rated on PGI-C as 'very much better' (30.5 vs diosmin 17.9%, p < 0.001) and shorter times to improvement (mean ± SD 3.9 ± 1.5 days vs diosmin 4.2 ± 1.7 days)" }, { "field": "followUp", "quote": "The 4-week observational prospective CHORALIS study" } ] }, { "id": "pmid:38698334", "pmid": "38698334", "doi": "10.1186/s12876-024-03228-5", "nctId": null, "pmcid": "PMC11064321", "title": "Haemorrhoidal disease in pregnancy: results from a self-assessment questionnaire administered by means of a social network", "firstAuthor": "D'Alfonso", "multipleAuthors": true, "journal": "BMC Gastroenterol", "year": 2024, "design": "retrospective", "n": 133, "nField": "reported", "population": "pregnant women surveyed through social media", "intervention": "no treatment tested; survey looked for risk factors like constipation, straining, low fibre and fluid intake", "comparator": "none - observational survey without a comparison group", "primaryOutcome": "incidence of hemorrhoid disease symptoms during pregnancy", "result": "51% of women reported hemorrhoid symptoms during pregnancy, mostly in later trimesters, with no resolution timeline given", "resultDirection": "unclear", "quality": "low", "qualityWhy": "It's a retrospective, self-reported online survey without clinical verification or follow-up, so it can't show whether or when hemorrhoids resolve.", "directness": "indirect", "limitations": "retrospective study via a self-assessment interview", "followUp": "", "plainFinding": "Doesn't address whether hemorrhoids resolve.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38698334/", "sourceText": "BACKGROUND: The anal symptoms occurring during pregnancy and post-partum, mainly related to Haemorrhoidal Disease (HD), have been reported with in a wide range of incidence in the literature. Although in many cases the course of the disease is mild and self-limiting, sometimes it is severe enough to affect quality of life. METHODS: Our study has been conducted through a questionnaire administered via social media with the aim of obtaining epidemiologic data on the incidence of the symptoms of HD in an unselected population of pregnant women. In addition, we looked for the presence of those factors notoriously predisposing or associated to HD (constipation, straining on the toilet, low dietary fibres and fluid intake). RESULTS: Out of 133 patients 51% reported symptoms of HD during pregnancy, mainly in the second and third trimester. Constipation, straining on the toilet, low dietary fibres and fluid intake were not significantly related to incidence of HD. Only a previous history of HD was correlated to onset of symptoms of HD in pregnancy and reached a statistical significance (odds ratio = 5.2, p < 0.001). CONCLUSION: Although with the limitations posed by the nature of our retrospective study via a self-assessment interview, our results suggest that the occurrence of HD in pregnancy seems not sustained by the classical risk factors observed in the general population. At the moment, specific therapeutic measures are lacking and treatment relies on empiric suggestions concerning diet, fluid intake, bowel care, local ointment. Further studies are needed in order to identify a targeted etiologic treatment.", "provenance": [ { "field": "n", "quote": "Out of 133 patients 51% reported symptoms of HD during pregnancy" }, { "field": "population", "quote": "an unselected population of pregnant women" }, { "field": "intervention", "quote": "we looked for the presence of those factors notoriously predisposing or associated to HD (constipation, straining on the toilet, low dietary fibres and fluid intake)" }, { "field": "comparator", "quote": "Our study has been conducted through a questionnaire administered via social media" }, { "field": "primaryOutcome", "quote": "obtaining epidemiologic data on the incidence of the symptoms of HD" }, { "field": "result", "quote": "Out of 133 patients 51% reported symptoms of HD during pregnancy, mainly in the second and third trimester." }, { "field": "limitations", "quote": "the limitations posed by the nature of our retrospective study via a self-assessment interview" } ] }, { "id": "pmid:38327723", "pmid": "38327723", "doi": "10.7759/cureus.53773", "nctId": null, "pmcid": "PMC10849161", "title": "Haemorrhoids and Anal Fissures in Pregnancy: Predictive Factors and Effective Treatments", "firstAuthor": "Boughton", "multipleAuthors": true, "journal": "Cureus", "year": 2024, "design": "prospective-cohort", "n": 258, "nField": "reported", "population": "pregnant women with hemorrhoids or anal fissures, surveyed before and after birth", "intervention": "no specific treatment tested; natural course observed, with some using conservative measures like dietary fibre", "comparator": "none (observational natural history, not a treatment trial)", "primaryOutcome": "how long it took for hemorrhoid/fissure symptoms to go away after birth", "result": "45% of postnatal patients' symptoms resolved within days, 27% within weeks, and 28% within months", "resultDirection": "unclear", "quality": "low", "qualityWhy": "This was a small, self-reported survey study without a control group testing treatment, so it can only loosely describe how long symptoms lasted, not prove what caused improvement.", "directness": "indirect", "limitations": "Self-reported diagnosis and symptoms, no control group for treatment comparison, single-centre study, selection bias from outpatient and ward recruitment.", "followUp": "", "plainFinding": "Most resolved within days to months.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38327723/", "sourceText": "Introduction Haemorrhoids and anal fissures (HAF) are common in pregnancy and can severely affect the quality of life of those suffering from them. Despite the condition being common, there is limited evidence, formal guidelines or recommendations on treatment, and little is known about the natural course during pregnancy. Methods This was a prospective, observational cohort study conducted at a tertiary-referral university maternity hospital (The National Maternity Hospital, Dublin), conducted over a nine-month period. The first part of the study was a case-control study of antenatal patients over 34 weeks' gestation. The second part of the study involved a cohort of postnatal patients. Anonymous patient surveys were performed and analysed. Results Two hundred and fifty-eight patients were recruited into the study from the outpatient clinics and wards of one maternity hospital from April to December 2021. Of the antenatal patients, 82/184 (45%) of these patients had symptoms of HAF and 102/184 (55%) antenatal patients were unaffected, acting as controls. In addition, 74 affected postnatal patients were also included. In the affected antenatal group, 36/82 (44%) of patients had self-reported HAF (symptoms or signs of HAF); 50/82 (61%) of patients diagnosed with HAF on their own. 12/82 (15%) noticed symptoms in the first trimester, 25/82 (30%) in the second and 45/82 (55%) in the third. 142/184 (77%) of antenatal patients used conservative methods to manage their symptoms, including an increase in dietary fibre. 144/184 (78%) used medical treatments including suppositories. Only one patient had surgery. 70/156 (45%) of postnatal patients' symptoms resolved within days, 42/156 (27%) in weeks and 44/156 (28%) within months. Conclusion HAF affect almost half of the pregnancies. Age over 35 was significantly associated with antenatal haemorrhoids or anal fissures. Concerningly, the majority of patients (64%) self-diagnose and manage the condition without either seeking or receiving guidance from medical professionals. In terms of the natural course of the disease, it was encouraging that 45% of patients' symptoms resolved within a few days. This will help when counselling patients with distressing symptoms. Conservative measures such as increased dietary fibre, increased fluid intake and bath salts were effective in relieving symptoms for the majority of patients.", "provenance": [ { "field": "n", "quote": "Two hundred and fifty-eight patients were recruited into the study from the outpatient clinics and wards of one maternity hospital from April to December 2021." }, { "field": "population", "quote": "Haemorrhoids and anal fissures (HAF) are common in pregnancy" }, { "field": "intervention", "quote": "142/184 (77%) of antenatal patients used conservative methods to manage their symptoms, including an increase in dietary fibre." }, { "field": "comparator", "quote": "This was a prospective, observational cohort study" }, { "field": "primaryOutcome", "quote": "little is known about the natural course during pregnancy" }, { "field": "result", "quote": "70/156 (45%) of postnatal patients' symptoms resolved within days, 42/156 (27%) in weeks and 44/156 (28%) within months." } ] }, { "id": "pmid:38151682", "pmid": "38151682", "doi": "10.1007/s13304-023-01741-y", "nctId": null, "pmcid": null, "title": "Thrombosed external hemorrhoids during pregnancy: surgery versus conservative treatment", "firstAuthor": "Medkova", "multipleAuthors": true, "journal": "Updates Surg", "year": 2024, "design": "prospective-cohort", "n": 53, "nField": "reported", "population": "pregnant women with thrombosed external hemorrhoids", "intervention": "surgery (local excision or thrombectomy) for thrombosed external hemorrhoids", "comparator": "conservative (non-surgical) treatment", "primaryOutcome": "pain and quality of life scores (VAS, CPGAS, SF-12) after treatment", "result": "Both treatments improved pain and quality of life, but surgery gave faster pain relief and better scores by day 10; thrombectomy had a higher rate of re-thrombosis than local excision", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Small number of patients, only part of the comparison was randomized, and the population (pregnant women) is specific, limiting how broadly the findings apply.", "directness": "indirect", "limitations": "Small sample size, randomization of the surgical subgroup was stopped early due to ethical concerns, and the study is specific to pregnant women rather than the general population.", "followUp": "3 and 10 days", "plainFinding": "Surgery relieved pain faster than waiting.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/38151682/", "sourceText": "The management of thrombosed external hemorrhoids (TEH) during pregnancy is still under debate because of the fear of potential adverse effects on the fetus. This study aims to compare efficacy and safety of conservative versus surgical treatment of acute TEH in pregnant women. Furthermore, the outcome of two different surgical approaches was evaluated. This is a prospective observational study including a sub-analysis on two randomized groups of pregnant women affected by TEH. The primary outcome measured was the impact of conservative and surgical treatment defined in terms of VAS, clinical patient grading assessment scale (CPGAS) and the SF-12 questionnaire. In a randomized sub-analysis of the surgical treatment, the outcome of local excision (LE) versus thrombectomy (TE) was compared. Fifty-three patients entered the study. Twenty-six patients had conservative treatment and 22 underwent surgery. Within the surgical group, 8 were randomized for TE and 14 for LE. VAS, SF-12 and CPGAS improved in both groups after 3 and 10 days from the treatment. However, physical (PCS) and mental health (MCS) domains of the SF-12 and CPGAS showed a significant difference in favor of surgery on the 10th day (PCS: p < 0.002 and MCS: p = 0.03; CPGAS: p = 0.002). The surgical group showed an earlier significant reduction of pain on the 3rd day (p = 0.0004). In the surgical group, randomization was halted due to ethical concerns arising from a notable difference in the primary end point between subgroups during interim analysis. Specifically, the re-thrombosis rate was 38% (3/8) after TE and 7% (1/14) after LE. No complications occurred for either mothers or fetuses. Both surgical and conservative treatments are safe and effective. However, surgery allows a faster relief of anal pain. Thrombectomy is associated with higher risk of re-thrombosis when compared to local excision (clinicaltrials.gov ID number NCT04588467).", "provenance": [ { "field": "n", "quote": "Fifty-three patients entered the study." }, { "field": "population", "quote": "pregnant women affected by TEH" }, { "field": "intervention", "quote": "surgical treatment of acute TEH in pregnant women" }, { "field": "comparator", "quote": "conservative versus surgical treatment" }, { "field": "primaryOutcome", "quote": "The primary outcome measured was the impact of conservative and surgical treatment defined in terms of VAS, clinical patient grading assessment scale (CPGAS) and the SF-12 questionnaire." }, { "field": "result", "quote": "The surgical group showed an earlier significant reduction of pain on the 3rd day (p = 0.0004)." }, { "field": "result", "quote": "the re-thrombosis rate was 38% (3/8) after TE and 7% (1/14) after LE" } ] }, { "id": "pmid:36658522", "pmid": "36658522", "doi": "10.1186/s12893-023-01910-1", "nctId": null, "pmcid": "PMC9850810", "title": "Comparision of Ligasure hemorrhoidectomy and conservative treatment for thrombosed external hemorrhoids (TEH) in pregnancy", "firstAuthor": "Luo", "multipleAuthors": true, "journal": "BMC Surg", "year": 2023, "design": "retrospective", "n": 94, "nField": "reported", "population": "pregnant women hospitalized for thrombosed external hemorrhoids", "intervention": "Ligasure hemorrhoidectomy surgery", "comparator": "conservative (non-surgical) treatment", "primaryOutcome": "symptom relief, recurrence and patient satisfaction", "result": "Surgery gave faster pain relief, quicker return to normal activities (6.51 vs 13.52 days), lower recurrence (8.57% vs 30.43%), and higher satisfaction than conservative treatment", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This is a retrospective, single-center study where patients chose their own treatment, so it cannot reliably prove cause and effect.", "directness": "indirect", "limitations": "This was a retrospective study with a limited number of patients, the data was obtained from only one center.", "followUp": "", "plainFinding": "Surgery recovered faster than conservative care.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/36658522/", "sourceText": "BACKGROUND: Ligasure hemorrhoidectomy for thrombosed external hemorrhoids in pregnancy has been rarely studied. OBJECTIVE: The purpose of this article is to study the efficacy and safety of Ligasure hemorrhoidectomy comparing with conservative treatment for thrombosed external hemorrhoids in pregnancy. DESIGN: This was a retrospective cohort study. SETTING: The patients were treated at a tertiary referral center in China. PATIENTS: 94 pregnant patients hospitalized for thrombosed external hemorrhoids from September 2020 to December 2021. INTERVENTIONS: Ligasure hemorrhoidectomy treatment or conservative treatment according to the patient's wishes. MAIN OUTCOME MEASURES: Symptom relief, recurrence and satisfaction of thrombosed external hemorrhoids in pregnancy with different interventions. RESULTS: There were no differences between groups in maternal age, gestational age, body mass index, parity, constipation and a prior history of thrombosed external hemorrhoids. The pain scores were less in surgical group than in conservative group in post-treatment days 1 and 7. Time to return to normal activities was shorter in surgical group than in conservative group (6.51 vs. 13.52 days, P < 0.001). Post-treatment complications were mild in surgical group and there were no significant differences concerning the rate of abortion, preterm birth, cesarean delivery and weight of fetus. Recurrence rate was significantly lower in surgical group (8.57% vs. 30.43%, P = 0.017). The patient satisfaction scores were significantly higher in surgical group than in conservative group (Z = - 2.979, P = 0.003). LIMITATIONS: This was a retrospective study with a limited number of patients, the data was obtained from only one center. CONCLUSIONS: Comparing with conservative treatment, Ligasure hemorrhoidectomy for TEH in pregnancy results in more rapid pain relief, shorter time to return to normal activities, lower incidence of recurrence, and better patient satisfaction. This type of surgery has low and mild postoperative complications, is not attended by any risk to the mother or her fetus.", "provenance": [ { "field": "n", "quote": "94 pregnant patients hospitalized for thrombosed external hemorrhoids from September 2020 to December 2021." }, { "field": "population", "quote": "94 pregnant patients hospitalized for thrombosed external hemorrhoids" }, { "field": "intervention", "quote": "Ligasure hemorrhoidectomy treatment or conservative treatment according to the patient's wishes." }, { "field": "comparator", "quote": "Ligasure hemorrhoidectomy treatment or conservative treatment according to the patient's wishes." }, { "field": "primaryOutcome", "quote": "Symptom relief, recurrence and satisfaction of thrombosed external hemorrhoids in pregnancy with different interventions." }, { "field": "result", "quote": "Time to return to normal activities was shorter in surgical group than in conservative group (6.51 vs. 13.52 days, P < 0.001)." }, { "field": "result", "quote": "Recurrence rate was significantly lower in surgical group (8.57% vs. 30.43%, P = 0.017)." } ] }, { "id": "pmid:35592120", "pmid": "35592120", "doi": "10.3389/fsurg.2022.898850", "nctId": null, "pmcid": "PMC9110961", "title": "Management and Treatment of External Hemorrhoidal Thrombosis", "firstAuthor": "Picciariello", "multipleAuthors": true, "journal": "Front Surg", "year": 2022, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "patients with external hemorrhoidal thrombosis (a painful swelling of hemorrhoids)", "intervention": "conservative treatments such as wait-and-see, flavonoids, lidocaine/nifedipine, botulinum toxin, or topical glyceryl trinitrate", "comparator": "surgical treatments such as drainage, excision, or stapled technique", "primaryOutcome": "which treatment approach works best for external hemorrhoidal thrombosis", "result": "abstract says both medical and surgical treatments have been shown to work but no clear guideline exists", "resultDirection": "unclear", "quality": "low", "qualityWhy": "this is a non-systematic review of other studies with no pooled data, no patient numbers, and the authors themselves say trials and guidelines are still lacking.", "directness": "indirect", "limitations": "abstract states management remains controversial, no specific guidelines exist, and randomized trials are still needed", "followUp": "", "plainFinding": "Unclear if it resolves alone.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35592120/", "sourceText": "BACKGROUND: External hemorrhoidal thrombosis (EHT) is a common complication of hemorrhoidal disease. This condition causes extreme pain, likely resulting from internal anal sphincter hypertonicity, which traps the hemorrhoids below the dentate line thus leading to congestion and swelling. The choice of treatment remains controversial and both conservative and surgical options have been proposed in the last decades. METHODS: This mini-review focuses on the most relevant studies found in literature evaluating conservative and surgical management of EHT. Special conditions such as pregnancy and EHT in elderly patients have been considered. RESULTS: Traditionally, symptoms duration represents the discriminant in the choice between medical and surgical treatment. Several Coloproctological Societies considered conservative treatment as the first-line approach to EHT and a variety of options have been proposed: wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection and topical application of 0.2% glyceryl trinitrate. Meanwhile, different surgical treatments are recommended when EHT fails to respond to conservative management or when symptoms onset falls within the last 48-72 h: drainage with radial incision, conventional excision, excision under local anesthesia and stapled technique. CONCLUSION: The management and treatment of EHT is still controversial since no specific guidelines have been published. Both medical and surgical treatment have been proven effective but randomized clinical trials and structured consensus-based guidelines are warranted.", "provenance": [ { "field": "population", "quote": "External hemorrhoidal thrombosis (EHT) is a common complication of hemorrhoidal disease." }, { "field": "intervention", "quote": "wait and see, mixture of flavonoids, mix of lidocaine and nifedipine, botulinum toxin injection and topical application of 0.2% glyceryl trinitrate" }, { "field": "comparator", "quote": "drainage with radial incision, conventional excision, excision under local anesthesia and stapled technique" }, { "field": "primaryOutcome", "quote": "The choice of treatment remains controversial and both conservative and surgical options have been proposed" }, { "field": "result", "quote": "Both medical and surgical treatment have been proven effective but randomized clinical trials and structured consensus-based guidelines are warranted." } ] }, { "id": "pmid:35064300", "pmid": "35064300", "doi": "10.1007/s00423-021-02415-2", "nctId": null, "pmcid": null, "title": "Perianal thrombosis: no need for surgery", "firstAuthor": "Alldinger", "multipleAuthors": true, "journal": "Langenbecks Arch Surg", "year": 2022, "design": "case-series", "n": 619, "nField": "reported", "population": "patients with thrombosed internal or external hemorrhoids (perianal thrombosis)", "intervention": "conservative treatment with sitz baths and oral pain medication, no surgery", "comparator": "none (all patients treated conservatively, no surgical comparison group)", "primaryOutcome": "pain resolution and healing without surgery", "result": "pain mostly resolved after 5 days and completely gone after 10 days, with a 6.3% recurrence rate", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was a single-center study with no comparison group and only partly prospective data, so it can't prove surgery is unnecessary, only describe what happened with conservative care.", "directness": "indirect", "limitations": "No control group, low-quality retrospective data acknowledged by authors, and data analysis was retrospective despite prospective collection", "followUp": "", "plainFinding": "Resolves within days without surgery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/35064300/", "sourceText": "AIM: There is little evidence for the best therapy for perianal thrombosis. No prospective trials exist. Even quality of retrospective data is low, due to low patient numbers or vague follow-up data. PATIENTS AND METHODS: Six hundred nineteen patients with thrombosis of internal or external hemorrhoids who presented in our clinic between March 2017 and August 2018 were enrolled in the study. All patients were treated conservatively, with sitz baths and oral pain medication, if needed. No surgery was performed. Follow-up data was obtained by personal examination. Data was gathered prospectively, and data analysis was retrospective. RESULTS: Five hundred four patients had perianal thrombosis (81.4%), and 115 patients had thrombosed hemorrhoids. Mean pain on a numerical rating scale (0-10) was 3.8 for perianal thrombosis and 5.2 for thrombosed hemorrhoids. Five hundred forty-eight patients (88.5%) did not need a sick leave. On follow-up, patients stated that their pain had largely resolved after 5 days and completely disappeared after 10 days. Local recurrence rate after perianal thrombosis was 6.3%. CONCLUSION: Perianal thrombosis and thrombosed hemorrhoids heal well without surgery. There is no evidence for advantages surgical therapy could offer.", "provenance": [ { "field": "n", "quote": "Six hundred nineteen patients with thrombosis of internal or external hemorrhoids who presented in our clinic between March 2017 and August 2018 were enrolled in the study." }, { "field": "population", "quote": "Six hundred nineteen patients with thrombosis of internal or external hemorrhoids who presented in our clinic" }, { "field": "intervention", "quote": "All patients were treated conservatively, with sitz baths and oral pain medication, if needed. No surgery was performed." }, { "field": "comparator", "quote": "All patients were treated conservatively, with sitz baths and oral pain medication, if needed. No surgery was performed." }, { "field": "primaryOutcome", "quote": "On follow-up, patients stated that their pain had largely resolved after 5 days and completely disappeared after 10 days." }, { "field": "result", "quote": "patients stated that their pain had largely resolved after 5 days and completely disappeared after 10 days. Local recurrence rate after perianal thrombosis was 6.3%." } ] }, { "id": "pmid:32223737", "pmid": "32223737", "doi": "10.2174/1574887115666200330162537", "nctId": null, "pmcid": null, "title": "The Management of Acute Hemorrhoidal Disease", "firstAuthor": "Selvaggi", "multipleAuthors": true, "journal": "Rev Recent Clin Trials", "year": 2021, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with sudden severe hemorrhoid problems (strangulated internal hemorrhoids or clotted external hemorrhoids)", "intervention": "urgent surgery done within 72 hours of symptoms starting", "comparator": "conservative (non-surgical) management", "primaryOutcome": "recovery time, complications, and need for later surgery", "result": "Early surgery within 72 hours was said to shorten recovery and reduce the need for later surgery compared with conservative treatment, which often led to prolonged recovery", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a narrative discussion piece, not a study with data, numbers, or a described research method, so it cannot reliably establish what works.", "directness": "indirect", "limitations": "No study design, patient numbers, or outcome data are given; statements appear to be expert opinion rather than reported results.", "followUp": "", "plainFinding": "Says early surgery speeds recovery.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/32223737/", "sourceText": "The acute strangulation of internal hemorrhoids and the thrombosis of external hemorrhoids are both debilitating and painful conditions which require immediate treatment in order to minimize morbidity and reduce the length of inactivity. In selected cases, urgent surgical treatment, performed within 72 hours of presentation, prevents the negative economic and psychological effects of a prolonged recovery (which is often the case of conservative management), and limits the necessity for surgical intervention at a later date.", "provenance": [ { "field": "population", "quote": "The acute strangulation of internal hemorrhoids and the thrombosis of external hemorrhoids" }, { "field": "intervention", "quote": "urgent surgical treatment, performed within 72 hours of presentation" }, { "field": "comparator", "quote": "conservative management" }, { "field": "primaryOutcome", "quote": "prevents the negative economic and psychological effects of a prolonged recovery" }, { "field": "result", "quote": "urgent surgical treatment, performed within 72 hours of presentation, prevents the negative economic and psychological effects of a prolonged recovery (which is often the case of conservative management), and limits the necessity for surgical intervention at a later date" } ] }, { "id": "pmid:30600960", "pmid": "30600960", "doi": "10.23736/S0026-4733.18.07724-6", "nctId": null, "pmcid": null, "title": "External hemorrhoidal thrombosis in the elderly patients: conservative and surgical management", "firstAuthor": "Eberspacher", "multipleAuthors": true, "journal": "Minerva Chir", "year": 2020, "design": "retrospective", "n": 87, "nField": "reported", "population": "elderly patients over 75 years old with external hemorrhoidal thrombosis (painful blood clot near the anus)", "intervention": "conservative medical treatment, or immediate incision and drainage of the clot, or surgical removal (hemorrhoidectomy)", "comparator": "the three treatment groups compared against each other", "primaryOutcome": "time for symptoms to go away, pain relief, bleeding, recurrence, and complications", "result": "Symptoms resolved in about 11.8 days with conservative treatment, 1.58 days with incision/drainage, and 7.8 days with surgical removal; recurrence was lowest after surgery", "resultDirection": "mixed", "quality": "low", "qualityWhy": "Patients chose their own treatment rather than being randomly assigned, the groups were small, and it was a single clinic's experience followed for about a year.", "directness": "indirect", "limitations": "Not randomized (patients selected their treatment after discussion), single-center, small subgroup sizes, and limited to elderly patients over 75 which may not reflect general population.", "followUp": "12.3 months", "plainFinding": "Resolved in about 12 days without surgery", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30600960/", "sourceText": "BACKGROUND: External hemorrhoidal thrombosis is a common disease with an acute anal pain as the major symptom. It is astonishing the lack of studies which investigates the most effective treatment and there are not guidelines. Furthermore, nobody has ever evaluated this peculiar condition in an elderly population. METHODS: We have considered 87 patients aged >75 years who were visited and treated for this condition in our clinic, dividing them in three groups according the curative option chosen together with them after anamnesis and an interview: a conservative medical treatment (Group A), an immediate incision and evacuation of the thrombus (Group B) and the excision of hemorrhoid with the thrombus, with hemorrhoidectomy technique (Group C). The mean follow-up was 12.3 months. We analyzed immediate pain relief and time of remission of symptoms, bleeding, recurrences and major complications. RESULTS: The Group A presented a remission of symptoms in 11.8 days, Group B in 1.58 ad Group C in 7.8 days. The recurrence rate was very similar for the first two options (19.4% and 16.1%) and lower in the excision group (no recurrence during follow-up). Bleeding is the common adverse event observed with a high frequency in the immediate incision and evacuation of thrombus, less common in hemorrhoidectomy, that did not present major complication. Surgical option is often refused by elderly patient evaluating comorbidities in the fear of adverse events. CONCLUSIONS: The surgical treatment for EHT in elderly is safe and effective, but not the most common choice for fear of complications. Medical treatment or immediate incision of thrombus can be preferred and well accepted by elderly even if followed by a higher rate of recurrences.", "provenance": [ { "field": "n", "quote": "87 patients aged >75 years" }, { "field": "population", "quote": "External hemorrhoidal thrombosis is a common disease with an acute anal pain as the major symptom" }, { "field": "population", "quote": "nobody has ever evaluated this peculiar condition in an elderly population" }, { "field": "intervention", "quote": "a conservative medical treatment (Group A), an immediate incision and evacuation of the thrombus (Group B) and the excision of hemorrhoid with the thrombus, with hemorrhoidectomy technique (Group C)" }, { "field": "comparator", "quote": "dividing them in three groups according the curative option chosen together with them after anamnesis and an interview" }, { "field": "primaryOutcome", "quote": "We analyzed immediate pain relief and time of remission of symptoms, bleeding, recurrences and major complications." }, { "field": "result", "quote": "The Group A presented a remission of symptoms in 11.8 days, Group B in 1.58 ad Group C in 7.8 days." }, { "field": "result", "quote": "The recurrence rate was very similar for the first two options (19.4% and 16.1%) and lower in the excision group (no recurrence during follow-up)." } ] }, { "id": "pmid:30276625", "pmid": "30276625", "doi": "10.1007/s12325-018-0794-x", "nctId": null, "pmcid": "PMC6223991", "title": "Conservative Treatment of Hemorrhoids: Results of an Observational Multicenter Study", "firstAuthor": "Zagriadskiĭ", "multipleAuthors": true, "journal": "Adv Ther", "year": 2018, "design": "prospective-cohort", "n": 1952, "nField": "reported", "population": "patients with symptomatic hemorrhoid disease", "intervention": "treatment with micronized purified flavonoid fraction (MPFF, Detralex), a conservative drug therapy", "comparator": "no comparison group; some patients also received invasive treatment", "primaryOutcome": "elimination of main hemorrhoid symptoms (bleeding and prolapse of internal nodes)", "result": "76.3% of patients had their main symptoms resolved with MPFF treatment", "resultDirection": "benefit", "quality": "low", "qualityWhy": "This was an uncontrolled observational study funded by the drug's manufacturer, so it cannot show whether symptoms would have improved without treatment.", "directness": "indirect", "limitations": "No control group, non-interventional design, industry funding, and some patients also received invasive procedures, making it impossible to isolate the drug's effect or assess natural resolution.", "followUp": "25-30 days", "plainFinding": "Drug eased symptoms, not natural course", "retracted": false, "expressionOfConcern": false, "hasErratum": true, "url": "https://pubmed.ncbi.nlm.nih.gov/30276625/", "sourceText": "INTRODUCTION: This study was conducted to determine the frequency of complaints in a cohort of patients with symptomatic hemorrhoidal disease (HD) treated with micronized purified flavonoid fraction (MPFF, Detralex). MPFF was selected for conservative treatment in this population owing to its proven effects on hemorrhoidal symptoms in a large number of patients. METHODS: This multicenter, non-interventional study was part of the international CHORUS survey (Chronic venous and HemORrhoidal diseases evalUation for improvement of Scientific knowledge), conducted in nine centers in different regions of Russia with the participation of 80 coloproctologists. The study enrolled consecutive patients with complaints of hemorrhoids. All were prescribed MPFF-based conservative treatment. The effect of treatment on HD clinical signs and symptoms was assessed at two follow-up visits performed 5-7 days and 25-30 days after enrollment. Surgical and minimally invasive treatment could be performed from day 7 onwards if required. RESULTS: A total of 1952 patients were enrolled. Over the entire period of observation, MPFF-based conservative treatment was effective in 1489 (76.3%) patients in eliminating the main clinical manifestations of disease, i.e., bleeding and prolapse of internal nodes. Invasive treatment was performed in 68 (3.5%) patients with grade IV hemorrhoids and was combined with MPFF conservative treatment in 395 (20.2%) patients with grades I-III hemorrhoids. CONCLUSION: Conservative therapy with MPFF was beneficial for relieving hemorrhoidal symptoms in the majority of patients. MPFF-based treatment was most effective in patients with grade I and II hemorrhoids before irreversible degenerative changes in ligaments of the hemorrhoidal plexuses have occurred. It was also beneficial in preventing disease relapse in patients with more advanced HD and for promoting optimal conditions in the postoperative period. FUNDING: Servier.", "provenance": [ { "field": "population", "quote": "patients with symptomatic hemorrhoidal disease (HD)" }, { "field": "intervention", "quote": "treated with micronized purified flavonoid fraction (MPFF, Detralex)" }, { "field": "comparator", "quote": "All were prescribed MPFF-based conservative treatment." }, { "field": "primaryOutcome", "quote": "eliminating the main clinical manifestations of disease, i.e., bleeding and prolapse of internal nodes" }, { "field": "result", "quote": "MPFF-based conservative treatment was effective in 1489 (76.3%) patients in eliminating the main clinical manifestations of disease" }, { "field": "n", "quote": "A total of 1952 patients were enrolled." }, { "field": "followUp", "quote": "assessed at two follow-up visits performed 5-7 days and 25-30 days after enrollment" } ] }, { "id": "pmid:30192331", "pmid": "30192331", "doi": "10.1097/DCR.0000000000001193", "nctId": null, "pmcid": null, "title": "The Effect of Nonoperative Management of Chronic Anal Fissure and Hemorrhoid Disease on Bowel Function Patient-Reported Outcomes", "firstAuthor": "Wilson", "multipleAuthors": true, "journal": "Dis Colon Rectum", "year": 2018, "design": "prospective-cohort", "n": 64, "nField": "reported", "population": "adults with chronic anal fissures or hemorrhoid disease seen at a colorectal surgery clinic", "intervention": "dietary counseling, fiber supplementation, toileting strategies (plus topical calcium channel blockers for fissure patients)", "comparator": "same patients' baseline scores before treatment", "primaryOutcome": "change in patient-reported bowel function scores", "result": "both conditions showed statistically significant improvement in several bowel function domains, including incontinence and stool-related symptoms for hemorrhoid disease", "resultDirection": "benefit", "quality": "low", "qualityWhy": "small, uncontrolled observational study with no comparison group and unclear treatment adherence, so it can't show whether symptoms would have improved without treatment.", "directness": "indirect", "limitations": "small cohort size and unclear patient adherence to medical management", "followUp": "", "plainFinding": "Diet and lifestyle changes eased symptoms.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/30192331/", "sourceText": "BACKGROUND: Nonoperative management has been reported to decrease symptoms from common anorectal conditions such as chronic anal fissures and hemorrhoids. The effects of these interventions on bowel function are unknown. OBJECTIVE: This study aims to perform a prospective evaluation of patient-reported outcomes of bowel function on nonoperative management for chronic anal fissures and hemorrhoid disease. DESIGN: This is a prospective, observational study. SETTINGS: Patient-reported outcome measures were collected from the clinical practice of the division of colon and rectal surgery at a tertiary colon and rectal surgery referral center. INTERVENTION: All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies. Those with chronic anal fissures were also prescribed topical calcium channel blockers. The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit. MAIN OUTCOME MEASURES: The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate. RESULTS: A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease. Incontinence, social impact, stool-related aspects, and the global score were observed to have statistically significant improvement in the aggregate group. When analyzed by diagnosis, hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects, whereas chronic anal fissure was associated with a statistically significant change in social impact, stool-related aspects, and the global score. LIMITATIONS: This study was limited by the small cohort size and unclear patient adherence to medical management. CONCLUSIONS: Nonoperative management of chronic anal fissures and hemorrhoid disease is associated with significant improvement in patient-reported outcome scores in several domains, suggesting that dietary counseling and medical therapy should be the first-line outpatient therapy for these diseases. See Video Abstract at http://links.lww.com/DCR/A726.", "provenance": [ { "field": "n", "quote": "A cohort of 64 patients was included, 37 patients (58%) with chronic anal fissure and 27 patients with hemorrhoid disease." }, { "field": "population", "quote": "chronic anal fissures and hemorrhoid disease" }, { "field": "intervention", "quote": "All patients received standardized dietary counseling including fiber supplementation as well as toileting strategies." }, { "field": "comparator", "quote": "The Colorectal Functional Outcome questionnaire was administered at baseline and at first follow-up visit." }, { "field": "primaryOutcome", "quote": "The primary outcomes measured were the mean change in patient-reported bowel function scores after nonoperative management for each disease and in aggregate." }, { "field": "result", "quote": "hemorrhoid disease demonstrated a statistically significant improvement in incontinence and stool-related aspects" }, { "field": "limitations", "quote": "This study was limited by the small cohort size and unclear patient adherence to medical management." } ] }, { "id": "pmid:28150480", "pmid": "28150480", "doi": "10.23736/S1121-421X.17.02364-9", "nctId": null, "pmcid": null, "title": "Adequate dietary fiber supplement and TONE can help avoid surgery in most patients with advanced hemorrhoids", "firstAuthor": "Garg", "multipleAuthors": true, "journal": "Minerva Gastroenterol Dietol", "year": 2017, "design": "case-series", "n": 102, "nField": "reported", "population": "adults with advanced (grade III or IV) hemorrhoids who had been referred for surgery", "intervention": "high-fiber diet (psyllium husk) plus counseling on bowel habits (the 'TONE' method: 3 minutes, once daily, no straining, enough fiber)", "comparator": "no comparison group; outcomes tracked before and after treatment in the same patients", "primaryOutcome": "improvement in hemorrhoid prolapse, bleeding episodes, and patient satisfaction", "result": "Most patients had less prolapse and fewer bleeding episodes, and only about 1 in 8 still needed surgery", "resultDirection": "benefit", "quality": "low", "qualityWhy": "this was a single-arm study with no comparison group and 17 of 102 patients lost to follow-up, so it cannot show whether the improvement was due to the treatment or would have happened anyway", "directness": "indirect", "limitations": "No control group, substantial loss to follow-up (17 of 102 patients), and reliance on patient-reported satisfaction and symptoms", "followUp": "40 (12-96) months", "plainFinding": "Fiber and bowel habits reduced hemorrhoid symptoms", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/28150480/", "sourceText": "BACKGROUND: The root cause of hemorrhoids resides in three deranged defecation habits (DDH), namely increased straining, prolonged defecation-time, and frequent bowel-motions. These DDH are responsible for the development of new hemorrhoids, progression of existing one and hemorrhoidal rupture (bleeding). DDH can be corrected with the help of the \"TONE\" mnemonic. TONE entails specifying exact treatment goals: T, three minutes at defecation; O, once-a-day defecation frequency; N, no straining during passing motions; E, enough fiber. TONE can be implemented by proper counseling and by prescribing fiber supplement appropriately (5-6 teaspoonfuls of psyllium husk with 600 mL of water daily. Corrected DDH would prevent the progression of hemorrhoids and bleeding episodes. An office procedure may be done to further downgrade the hemorrhoids. METHODS: Patients with advanced hemorrhoids (grades III and IV) who were referred for surgery were prescribed fiber supplement and were counseled to follow TONE. The outcome parameters evaluated were improvement in prolapse, bleeding episodes, satisfaction levels. RESULTS: A total of 102 patients (75 males and 10 females, mean age 46.0±13.5 years, 17 lost to follow-up) with advanced hemorrhoids (41 with early grade III, 38 with late grade III, and 6 with grade IV) were included in the study. All patients had symptoms of prolapsed hemorrhoids and bleeding episodes were present in 71.8% (61/85) of patients. After the follow-up of 40 (12-96) months, 68.2% (58/85) patients were highly satisfied, 12.9% (11/85) were moderately satisfied and 18.9% (16/85) were not satisfied with treatment. Prolapse improved in 56.5% (48/85), did not progress over time in 25.9 (22/85) and continued to progress in 4.7% (4/85) patients. 12.9% (11/85) underwent operation for hemorrhoids. Bleeding episodes decreased from 71.8% (61/85) to 29.4% (25/85) (P<0.0001). CONCLUSIONS: Adequate fiber supplement combined with the TONE method can correct DDH, thus stopping the progression of hemorrhoids and bleeding, and preventing surgery in most patients with advanced hemorrhoids.", "provenance": [ { "field": "n", "quote": "A total of 102 patients (75 males and 10 females, mean age 46.0±13.5 years, 17 lost to follow-up)" }, { "field": "population", "quote": "Patients with advanced hemorrhoids (grades III and IV) who were referred for surgery" }, { "field": "intervention", "quote": "were prescribed fiber supplement and were counseled to follow TONE" }, { "field": "comparator", "quote": "Patients with advanced hemorrhoids (grades III and IV) who were referred for surgery were prescribed fiber supplement and were counseled to follow TONE." }, { "field": "primaryOutcome", "quote": "The outcome parameters evaluated were improvement in prolapse, bleeding episodes, satisfaction levels." }, { "field": "result", "quote": "Prolapse improved in 56.5% (48/85), did not progress over time in 25.9 (22/85) and continued to progress in 4.7% (4/85) patients. 12.9% (11/85) underwent operation for hemorrhoids. Bleeding episodes decreased from 71.8% (61/85) to 29.4% (25/85) (P<0.0001)." }, { "field": "result", "quote": "68.2% (58/85) patients were highly satisfied, 12.9% (11/85) were moderately satisfied and 18.9% (16/85) were not satisfied with treatment." } ] }, { "id": "pmid:24606821", "pmid": "24606821", "doi": "10.1067/j.cpsurg.2013.11.002", "nctId": null, "pmcid": null, "title": "Hemorrhoids and fistulas: new solutions to old problems", "firstAuthor": "Rakinic", "multipleAuthors": true, "journal": "Curr Probl Surg", "year": 2014, "design": "narrative-review", "n": null, "nField": "not-reported", "population": "people with symptoms thought related to hemorrhoids", "intervention": "conservative management (fluid, fiber, toileting changes), office-based procedures, or operative surgery depending on grade", "comparator": "different hemorrhoid treatment options compared to each other by severity grade", "primaryOutcome": "whether symptoms (especially bleeding) improve with each level of treatment", "result": "conservative management is tried first; office-based therapies help lower-grade bleeding; surgery is best for higher-grade or persistent symptomatic hemorrhoids", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "This is a general review discussing treatment choices, not a study measuring whether hemorrhoids resolve on their own or how long that takes.", "directness": "indirect", "limitations": "Abstract does not discuss natural history or spontaneous resolution of hemorrhoids, only treatment escalation strategy.", "followUp": "", "plainFinding": "Discusses treatments, not natural resolution.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/24606821/", "sourceText": "Symptoms thought related to hemorrhoids must be carefully considered before intervention. The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior. Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies; some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required. Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well. With proper patient selection and preparation, along with a familiarity with instrumentation and techniques, good results can be obtained with newer operative interventions for internal hemorrhoids. Outcomes must always be compared with those obtained with classic excisional hemorrhoidectomy.", "provenance": [ { "field": "population", "quote": "Symptoms thought related to hemorrhoids must be carefully considered before intervention." }, { "field": "intervention", "quote": "The first line of therapy for any hemorrhoidal complaint remains conservative management with increased fluid and fiber intake and appropriate modification of toileting behavior." }, { "field": "comparator", "quote": "Operative therapy is the best choice for management of persistently symptomatic grade 2 disease and for grades 3 and 4 symptomatic hemorrhoids as well." }, { "field": "primaryOutcome", "quote": "Bleeding in grades 1 and 2 hemorrhoids that does not respond to this can be satisfactorily and safely managed with office-based therapies" }, { "field": "result", "quote": "some grade 3 hemorrhoids would also respond to this, though more treatment sessions would likely be required." } ] }, { "id": "pmid:23347777", "pmid": "23347777", "doi": "10.1016/j.ejso.2013.01.001", "nctId": null, "pmcid": null, "title": "Contemporary management of perianal conditions in febrile neutropenic patients", "firstAuthor": "Morcos", "multipleAuthors": true, "journal": "Eur J Surg Oncol", "year": 2013, "design": "retrospective", "n": 933, "nField": "reported", "population": "adult patients with fever and low white blood cell counts (from cancer treatment) who had perianal complaints", "intervention": "conservative (non-surgical) treatment of perianal conditions including piles", "comparator": "surgical drainage or debridement", "primaryOutcome": "type, frequency, management and outcome of perianal conditions", "result": "most perianal conditions, including piles, were not infected and were treated conservatively without surgery", "resultDirection": "unclear", "quality": "very-low", "qualityWhy": "this is a retrospective chart review in a very different patient group (cancer patients with low immunity), not designed to track how long hemorrhoids take to resolve on their own.", "directness": "indirect", "limitations": "retrospective design, population is immunocompromised neutropenic patients rather than general hemorrhoid patients, and no timeframe for resolution of piles is given.", "followUp": "", "plainFinding": "No info on resolution time.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23347777/", "sourceText": "INTRODUCTION: The aim of this study was to examine the type and frequency of perianal conditions in a contemporary series of febrile neutropenic patients and to examine the risk factors, management options and outcome of septic perianal conditions. METHODS: Medical records of all adult febrile neutropenic patients (933 patients) who were admitted during the period from January, 2009 to December 2011 were retrospectively review. All patients with perianal complaints or conditions were included. The clinical features, management and outcome of septic conditions were recorded. RESULTS: Of all the reviewed charts, 101 (10.8%) had perianal complaints or conditions. Most of them were non septic (74.3%), like piles and fissures, and were treated conservatively. In 26 patients the diagnosis was a septic condition: abscess (12 patients), fistula (4), inflammation (9) and necrotizing fasciitis (1). Septic conditions were more commonly found in males younger than 40 years. Surgery was done in 13 patients to drain a collection and in 2 patients to debride necrotic tissue. Most patients who had no collection had conservative management. There was 1 fatality only (3.8%) in those 26 patients. CONCLUSION: Most of the perianal conditions in febrile neutropenic patients are non septic and are managed conservatively. Septic perianal conditions are not associated with a poor prognosis as in the past. Surgical drainage should be reserved to conditions where there is a collection; otherwise patients should be managed conservatively but with close monitoring.", "provenance": [ { "field": "n", "quote": "933 patients" }, { "field": "population", "quote": "all adult febrile neutropenic patients" }, { "field": "intervention", "quote": "Most of them were non septic (74.3%), like piles and fissures, and were treated conservatively." }, { "field": "comparator", "quote": "Surgery was done in 13 patients to drain a collection and in 2 patients to debride necrotic tissue." }, { "field": "primaryOutcome", "quote": "The aim of this study was to examine the type and frequency of perianal conditions in a contemporary series of febrile neutropenic patients and to examine the risk factors, management options and outcome of septic perianal conditions." }, { "field": "result", "quote": "Most of them were non septic (74.3%), like piles and fissures, and were treated conservatively." } ] }, { "id": "pmid:23125506", "pmid": "23125506", "doi": "10.4103/0975-9476.100169", "nctId": null, "pmcid": "PMC3487235", "title": "Management of internal hemorrhoids by Kshara karma: An educational case report", "firstAuthor": "Mahapatra", "multipleAuthors": true, "journal": "J Ayurveda Integr Med", "year": 2012, "design": "case-series", "n": 1, "nField": "reported", "population": "66-year-old man with internal hemorrhoids causing prolapse and bleeding during bowel movements", "intervention": "Kshara karma (applying a caustic alkaline paste) to the hemorrhoids under local anesthesia", "comparator": "No comparator", "primaryOutcome": "Resolution of pile mass, bleeding, and symptoms", "result": "Pile mass and bleeding resolved in 8 days, all symptoms gone by 21 days, no recurrence on long-term follow-up", "resultDirection": "benefit", "quality": "very-low", "qualityWhy": "This is a single patient case report with no comparison group, so it cannot show whether hemorrhoids would have improved without treatment.", "directness": "indirect", "limitations": "Single case report, no control group, treatment was an active procedure not natural resolution, so it does not directly answer whether hemorrhoids resolve untreated.", "followUp": "followed up regularly from 2004 onward till date", "plainFinding": "Resolved after treatment, not on its own", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23125506/", "sourceText": "A 66-year-old male patient came to the anorectal clinic, Outpatient department, AVT Institute for Advanced Research, Coimbatore, Tamil Nadu, with complaints of prolapsing pile mass during defecation and bleeding while passing stool. The case was diagnosed as \"Raktarsha\" - 11 & 7 'o' clock position II degree internal hemorrhoids, deeply situated, projecting one and caused by pitta and rakta; with bleeding tendency. Kshara karma (application of caustic alkaline paste) intervention was done in this case to internal hemorrhoids under local anesthesia. The pile mass and per rectal bleeding resolved in 8 days and the patient was relieved from all symptoms within 21 days. No complications were reported after the procedure. The patient was followed up regularly from 2004 onward till date and proctoscopic examination did not reveal any evidence of recurrence of the hemorrhoids.", "provenance": [ { "field": "n", "quote": "A 66-year-old male patient came to the anorectal clinic" }, { "field": "population", "quote": "with complaints of prolapsing pile mass during defecation and bleeding while passing stool" }, { "field": "intervention", "quote": "Kshara karma (application of caustic alkaline paste) intervention was done in this case to internal hemorrhoids under local anesthesia" }, { "field": "comparator", "quote": "Kshara karma (application of caustic alkaline paste) intervention was done in this case to internal hemorrhoids under local anesthesia" }, { "field": "primaryOutcome", "quote": "The pile mass and per rectal bleeding resolved in 8 days and the patient was relieved from all symptoms within 21 days" }, { "field": "result", "quote": "The pile mass and per rectal bleeding resolved in 8 days and the patient was relieved from all symptoms within 21 days. No complications were reported after the procedure." } ] }, { "id": "pmid:23079956", "pmid": "23079956", "doi": "10.1007/s10151-012-0904-8", "nctId": null, "pmcid": null, "title": "External haemorrhoidal thrombosis: evidence for current management", "firstAuthor": "Chan", "multipleAuthors": true, "journal": "Tech Coloproctol", "year": 2013, "design": "systematic-review", "n": 819, "nField": "reported", "population": "people with external hemorrhoidal thrombosis (a type of hemorrhoid clot)", "intervention": "conservative (non-surgical) treatment", "comparator": "surgical excision", "primaryOutcome": "how quickly symptoms go away", "result": "surgery relieves symptoms faster than conservative treatment, but with conservative treatment symptoms last over 3 weeks", "resultDirection": "mixed", "quality": "low", "qualityWhy": "only a handful of studies were found and most evidence was low-grade, so conclusions are weak.", "directness": "direct", "limitations": "only two prospective studies (248 patients) and two retrospective studies (571 patients) were found, and the review notes a 'remarkable paucity of studies' with few providing high-quality evidence.", "followUp": "", "plainFinding": "Conservative treatment: symptoms last over 3 weeks.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/23079956/", "sourceText": "BACKGROUND: External haemorrhoidal thrombosis (EHT) may be managed surgically or conservatively. The optimal treatment is, however, unclear, as is the long-term outcome following treatment. METHODS: A literature search was undertaken to review and grade the evidence available for EHT management, determine the optimal management modality and assess long-term outcome after each treatment. RESULTS: Among 800 articles on haemorrhoids, only two prospective studies encompassing 248 patients and two retrospective studies of 571 patients were found. Excision significantly relieves presenting symptoms by postoperative day 4 compared with incision or topical GTN (Level IB evidence). Symptoms last over 3 weeks with conservative treatment (Level III evidence) and this period may be reduced by combining topical nifedipine and lignocaine rather than using lignocaine alone (Level IB evidence). There is no evidence regarding the optimal time for non-surgical options. CONCLUSIONS: There is a remarkable paucity of studies on EHT and few of those available provide high levels of evidence. Surgery may be superior to conservative treatment but there is no evidence regarding the optimal period of initiation of conservative management. Prospective comparative studies are needed.", "provenance": [ { "field": "n", "quote": "two prospective studies encompassing 248 patients and two retrospective studies of 571 patients" }, { "field": "population", "quote": "External haemorrhoidal thrombosis (EHT) may be managed surgically or conservatively." }, { "field": "intervention", "quote": "Symptoms last over 3 weeks with conservative treatment (Level III evidence)" }, { "field": "comparator", "quote": "Excision significantly relieves presenting symptoms by postoperative day 4 compared with incision or topical GTN (Level IB evidence)." }, { "field": "primaryOutcome", "quote": "determine the optimal management modality and assess long-term outcome after each treatment" }, { "field": "result", "quote": "Symptoms last over 3 weeks with conservative treatment (Level III evidence)" } ] }, { "id": "pmid:21694829", "pmid": "21694829", "doi": "10.2147/ceg.s5986", "nctId": null, "pmcid": "PMC3108631", "title": "Do we at all need surgery to treat thrombosed external hemorrhoids? Results of a prospective cohort study", "firstAuthor": "Gebbensleben", "multipleAuthors": true, "journal": "Clin Exp Gastroenterol", "year": 2009, "design": "prospective-cohort", "n": 72, "nField": "reported", "population": "adults with thrombosed external hemorrhoids", "intervention": "no surgery, conservative care (gentle dry cleaning, no sitz baths)", "comparator": "none (single group, no surgical comparison arm)", "primaryOutcome": "self-reported healing or improvement at 6 months", "result": "About 63% said they were healed or improved without surgery after 6 months", "resultDirection": "benefit", "quality": "low", "qualityWhy": "Small single-group study with no comparison group and self-reported outcomes, so it can't prove surgery is unnecessary, only that many improved without it.", "directness": "direct", "limitations": "No control/surgical comparison group, follow-up relied on patient questionnaire, and some patients did not respond.", "followUp": "six months", "plainFinding": "Most improved without surgery by 6 months.", "retracted": false, "expressionOfConcern": false, "hasErratum": false, "url": "https://pubmed.ncbi.nlm.nih.gov/21694829/", "sourceText": "BACKGROUND: It is unknown whether surgery is the gold standard for therapy of thrombosed external hemorrhoids (TEH). METHODS: A prospective cohort study of 72 adults with TEH was conducted: no surgery, no sitz baths but gentle dry cleaning with smooth toilet paper after defecation. Follow-up information was collected six months after admission by questionnaire. RESULTS: Despite our strict conservative management policy 62.5% (45/72) of patients (95% confidence interval [CI]: 51.0-74.0) described themselves as \"healed\" or \"ameliorated\", and 61.1% (44/72, 95% CI: 49.6-72.6) found our management policy as \"valuable to test\" or \"impracticable\". 13.9% (10/72, 95% CI: 5.7-22.1) of patients suspected to have recurrences. 4.2% did not know. Twenty-two of the 48 responding patients reported symptoms such as itching (18.8%), soiling (12.5%), pricking (10.4%), or a sore bottom (8.3%) once a month (59.1%, 13/22), once a week (27.3%, 6/22), or every day (13.6%, 3/22). CONCLUSIONS: The dictum that surgery is the gold standard for therapy for TEH should be checked by randomized controlled trials.", "provenance": [ { "field": "population", "quote": "72 adults with TEH" }, { "field": "intervention", "quote": "no surgery, no sitz baths but gentle dry cleaning with smooth toilet paper after defecation" }, { "field": "comparator", "quote": "A prospective cohort study of 72 adults with TEH was conducted: no surgery, no sitz baths but gentle dry cleaning with smooth toilet paper after defecation." }, { "field": "primaryOutcome", "quote": "Follow-up information was collected six months after admission by questionnaire." }, { "field": "result", "quote": "62.5% (45/72) of patients (95% confidence interval [CI]: 51.0-74.0) described themselves as \"healed\" or \"ameliorated\"" }, { "field": "n", "quote": "72 adults with TEH" }, { "field": "followUp", "quote": "Follow-up information was collected six months after admission by questionnaire." } ] } ], "faqs": [ { "q": "Do hemorrhoids go away on their own?", "a": "The evidence is thin and mixed. Only two studies looked at this directly, and both were about a clotted external hemorrhoid, not hemorrhoids in general. One found symptoms often lasted over three weeks without treatment; the other found about 63% felt healed or improved after six months without surgery." }, { "q": "How long do hemorrhoids last?", "a": "For a thrombosed external hemorrhoid (a clot), small studies report anywhere from about 10 days to over three weeks for symptoms to ease without surgery. There is no good data on how long bleeding or swelling from internal hemorrhoids takes to settle." }, { "q": "Do hemorrhoid skin tags go away?", "a": "No study has tracked this. We don't have evidence on whether skin tags left by a hemorrhoid shrink, stay the same, or disappear over time." }, { "q": "Do internal hemorrhoids go away on their own?", "a": "No study has directly followed untreated internal hemorrhoids to see if they resolve. The only direct evidence we have is about a different type — a clotted external hemorrhoid — so this question remains unanswered." }, { "q": "Do external hemorrhoids go away on their own?", "a": "For a thrombosed (clotted) external hemorrhoid specifically, small studies suggest symptoms often ease within a few weeks without surgery, and about six in ten people felt healed or improved by six months. This has not been studied for external hemorrhoids that are not clotted." } ], "searchedAs": [ "do hemorrhoids go away", "do hemorrhoids go away on their own", "how long do hemorrhoids last", "how long does it take for hemorrhoids to go away", "do hemorrhoid skin tags go away", "do internal hemorrhoids go away", "do external hemorrhoids go away", "do hemorrhoids go away with time" ], "patientTakeaway": "We can't honestly promise your hemorrhoid will go away on its own, or tell you exactly how long it will take — the research on this is too thin and too mixed. What the small studies do suggest is that a painful clotted hemorrhoid often eases over one to three weeks with simple care like warm baths and pain relief. If symptoms are severe, keep bleeding, or aren't easing after a couple of weeks, see a doctor rather than waiting it out.", "methodology": { "databases": [ "PubMed", "ClinicalTrials.gov", "Crossref" ], "searchStrings": { "pubmed": "(\"Hemorrhoids\"[Mesh] OR hemorrhoid*[tiab] OR haemorrhoid*[tiab] OR piles[tiab]) AND (\"natural history\"[tiab] OR \"spontaneous resolution\"[tiab] OR \"self-limiting\"[tiab] OR \"remission, spontaneous\"[Mesh] OR \"disease progression\"[Mesh] OR \"watchful waiting\"[tiab] OR \"conservative treatment\"[Mesh] OR \"conservative management\"[tiab] OR untreated[tiab] OR resolve*[tiab] OR \"time course\"[tiab])" }, "pubmedQueryTranslation": "(\"Hemorrhoids\"[MeSH Terms] OR \"hemorrhoid*\"[Title/Abstract] OR \"haemorrhoid*\"[Title/Abstract] OR \"piles\"[Title/Abstract]) AND (\"natural history\"[Title/Abstract] OR \"spontaneous resolution\"[Title/Abstract] OR \"self-limiting\"[Title/Abstract] OR \"remission, spontaneous\"[MeSH Terms] OR \"disease progression\"[MeSH Terms] OR \"watchful waiting\"[Title/Abstract] OR \"conservative treatment\"[MeSH Terms] OR \"conservative management\"[Title/Abstract] OR \"untreated\"[Title/Abstract] OR \"resolve*\"[Title/Abstract] OR \"time course\"[Title/Abstract])", "searchedOn": "2026-10-13", "inclusion": [ "Human, animal or laboratory studies reporting an outcome relevant to the question" ], "exclusion": [ "Records about a different condition or intervention", "Records reporting no outcome", "Retracted publications, which are listed but excluded from every count" ], "extractionLevel": "abstract", "gradingNote": "Evidence strength is adapted from the GRADE framework. It is not a GRADE assessment and was not produced by a GRADE panel.", "limits": [ "Fields were read from abstracts, not full text, so detail reported only in a paper's methods section is not captured." ] }, "seo": { "title": "Do Hemorrhoids Go Away on Their Own?", "description": "Evidence on whether hemorrhoids heal without treatment is thin and mixed. See what the small number of studies that tested this actually found." }, "lastChecked": "2026-10-13", "lastChanged": "2026-10-13", "nextCheckDue": "2026-11-13", "history": [], "pipeline": { "screenModel": "claude-haiku-4-5", "extractModel": "claude-sonnet-5", "composeModel": "claude-sonnet-5", "promptVersion": "ev-1", "ranOn": "2026-10-13" }, "status": "published" }