Davis BR, Lee-Kong SA, Migaly J, Feingold DL, Steele SR. The American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. Dis Colon Rectum. 2018 Mar;61(3):284-292.

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“Symptoms related to hemorrhoids are very common in the Western hemisphere and other industrialized societies. Although published estimates of prevalence are varied,1,2 it represents one of the most common medical and surgical disease processes encountered in the United States, resulting in >2.2-million outpatient evaluations per year.3 A large number of diverse symptoms may be, correctly or incorrectly, attributed to hemorrhoids by both patients and referring physicians. As a result, it is important to identify symptomatic hemorrhoids as the underlying source of the anorectal symptom and to have a clear understanding of the evaluation and management of this disease process.These guidelines address both diagnostic and therapeutic modalities in the management of hemorrhoidal disease.”

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Muldoon R. Review of American Society of Colon and Rectal Surgeons Clinical Practice Guidelines for the Management of Hemorrhoids. JAMA Surg. 2020 Jun 17.

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Major recommendations and quality of evidence ratings:

Complete endoscopic evaluation of the colon is indicated in selected patients with symptomatic hemorrhoids and rectal bleeding (strong recommendation; 1C).

Dietary modifications consisting of adequate fluid and fiber intake and counseling regarding defecation habits typically form the primary first-line therapy for patients with symptomatic hemorrhoid disease (strong recommendation; 1B).

Medical therapy for hemorrhoids can be offered with expectations of minimal harm and decent potential for relief (weak recommendation; 2B).

Most patients with grade I and II and selected grade III internal hemorrhoidal disease with failed medical treatment can be effectively treated with office-based procedures, such as rubber band ligation, sclerotherapy, and infrared coagulation. Hemorrhoid banding is typically the most effective option (strong recommendation; 1A).

Hemorrhoidectomy should typically be offered to patients whose symptoms result from external hemorrhoids or combined internal and external hemorrhoids with prolapse (strong recommendation; 1A).