Medications for treatment of symptomatic hemorrhoids in nonpregnant adults*

Drug	Dose	Role and precautions
Treatment
Anesthetics, local
Dibucaine 1% rectal ointment	Sparingly as needed up to four times per day	Temporary relief of acute pain and pruritus. Intended for short-term, intermittent use. For external use only. Local burning is common. Systemic absorption is variable.
Pramoxine 1% rectal foam	As needed up to five times per day
Astringent and protectants, topical
Witch hazel pads	As needed up to six times per day or after each bowel movement	Provides temporary relief of pruritus and irritation. Witch hazel may dry secretions and tighten tissues. Zinc oxide has protectant, astringent, and antiseptic properties. Well tolerated; rare allergy.
Zinc oxide topical paste	As needed
Corticosteroids, topical
Hydrocortisone rectal cream 1 to 2.5%	Rectal cream: Apply sparingly as needed up to two times per day	Provides local anti-inflammatory and analgesic effect. For intermittent short-term use (ie, no more than 7 days) due to risk of mucosal thinning. Avoid in persons with local infection. Variable systemic absorption; caution in pregnancy.
Hydrocortisone rectal suppository 25 to 30 mg	Suppository: 1 suppository per rectum as needed up to two times per day
Vasoactive agents, topical
Nitroglycerin (glyceryl trinitrate) 0.2 to 0.5% ointment*	Apply pea-sized amount two times per day	Potential option for managing pain associated with anal sphincter spasm or thrombosed external hemorrhoids. Systemic adverse effects (eg, headache) are common.
Phenylephrine 0.25% rectal ointment or suppository (eg, Preparation-H)	Ointment: Apply as needed up to four times per day Suppository: 1 suppository per rectum as needed up to four times per day	Frequent choice for temporary relief of acute symptoms (ie, bleeding or pain on defecation). Well tolerated; rare systemic effects. Ointment may be applied externally or inserted per rectum using applicator.
Combination anesthetic and corticosteroid, topical
Lidocaine and hydrocortisone cream (eg, lidocaine-hydrocortisone 2%-2%, 3%-0.5%, and 3%-1%)^¶ Lidocaine and hydrocortisone gel (eg, lidocaine-hydrocortisone 2.8%-0.55% and 3%-2.5%)^¶	Cream or gel: Apply as needed up to two times per day	Temporary relief of acute pain and pruritus; local anti-inflammatory effect. For intermittent short-term use (ie, no more than 7 days) due to risk of mucosal thinning and contact dermatitis. May be applied externally or inserted per rectum using applicator. Avoid in persons with local infection. Variable systemic absorption; caution in pregnancy.
Prevention
Bulk-forming laxatives (ie, fiber supplements), oral^Δ
Methylcellulose	Initially 1 tablespoon (≅2 grams fiber) or 4 caplets (500 mg fiber per caplet) once per day; may increase to 1 tablespoon or 4 caplets three times per day	Reduces bleeding and possibly symptoms in nonprolapsing hemorrhoids; gradual onset of effect over 6 weeks or more. Useful in patients with inadequate dietary fiber intake who may be at risk for constipation or diarrhea. Adequate oral fluid intake required; administer with 180 to 360 mL (6 to 12 ounces) water or fruit juice. Gradually increase dose as needed to minimize gas and bloating. Do not administer within 1 hour of other medications.
Polycarbophil	Initially 1 to 2 tablets (500 mg fiber per tablet) per day; may increase to 2 to 4 tablets per day
Psyllium	Initially 1 tablespoon (≅3.5 grams fiber) once per day; may increase to 1 tablespoon three times per day
Wheat dextrin	Initially 1 caplet (1 gram fiber) or 1 teaspoonful (1.5 grams fiber) per day; may increase to 3 caplets or 2 teaspoonfuls three times per day
Stool softeners, oral
Docusate sodium	100 mg orally two times per day	Decreases straining. Well tolerated. Use lower dose if administered with another laxative.

Medical therapy for internal hemorrhoids may be useful for controlling symptoms in lower-grade disease and acute bleeding in higher-grade hemorrhoids pending definitive therapy (eg, banding, sclerotherapy, cryotherapy, or surgery).
Before applying topical preparations, the affected area should be gently cleansed and allowed to dry.
A large number of topical preparations are available in addition to those listed in the table; evidence of efficacy for most is lacking.
Medications in this table are available without a prescription (over the counter) in the United States, except where noted.

* Nitroglycerin 0.4% rectal ointment is available as a prescription product in the United States and other countries and has been studied for anal fissure. Other strengths of nitroglycerin ointment shown in the table are not commercially available products in the United States.

¶ Available only as a prescription product in the United States.

Δ A high-fiber diet and increased fluid intake is recommended in most patients with hemorrhoidal disease to soften stools and prevent the need for straining. Patients should also be counseled to avoid prolonged sitting or straining on the toilet, on improving anal hygiene, and on avoiding triggers for constipation or diarrhea. Recommendations on dietary fiber intake are provided elsewhere in UpToDate.

Prepared with data from:

Hall JF. Modern management of hemorrhoidal disease. Gastroenterol Clin N Am 2013; 42:759.
Lorsiriwat V. Hemorrhoids: From basic pathophysiology to clinical management. World J Gastroenterol 2012; 18:2009.
Madoff RD, Fleshman JW. American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids. Gastroenterology 2004; 126:1463.

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Medications for treatment of symptomatic hemorrhoids in nonpregnant adults*