External hemorrhoids are swollen veins that develop beneath the skin just outside the anal opening. While the term “removal” often suggests a medical procedure, the majority of external hemorrhoids can be managed effectively without formal surgery. These methods focus on reducing the swelling and alleviating the discomfort until the inflamed tissue naturally shrinks and resolves. The primary goal of non-surgical management is to control symptoms and correct the underlying factors that caused the veins to swell.
Symptom Relief and Conservative Care
Conservative care is the first-line approach for managing external hemorrhoids, aiming to reduce inflammation and promote natural healing. This management begins with adjustments to daily habits, particularly those related to bowel movements. Increasing dietary fiber intake to between 25 and 35 grams per day helps create softer, bulkier stools. This reduces pressure and strain on the rectal veins during passage.
Adequate fluid consumption must accompany increased fiber intake to ensure the stool remains soft and prevent constipation. Stool softeners or osmotic laxatives may be used short-term to prevent straining during defecation, as excessive pushing contributes to flare-ups. It is also beneficial to avoid prolonged sitting on the toilet, which increases pressure in the anal veins.
Topical treatments provide immediate symptom relief by targeting pain, swelling, and itching. Over-the-counter creams, ointments, or suppositories containing hydrocortisone can be used for a short duration, typically no more than a week, to decrease local inflammation. Pads containing witch hazel are commonly used for their astringent properties. These help soothe the area and reduce swelling.
Warm water soaks, known as sitz baths, are an effective way to relieve discomfort and relax the anal sphincter muscles. Soaking the anal area in plain warm water for 10 to 15 minutes, two or three times a day, can significantly reduce pain and irritation. While mild external hemorrhoids often resolve within a week, larger or more persistent cases may take two to four weeks to shrink completely.
Addressing Thrombosed External Hemorrhoids
A thrombosed external hemorrhoid is a sudden, hard, and painful lump formed when a blood clot (thrombus) develops within the swollen vein. Severe pain typically peaks within the first 48 to 72 hours of onset. Although the body can eventually reabsorb the clot over several weeks, a procedure is often recommended for faster relief.
If medical attention is sought within the critical 72-hour window, a minor, office-based external hemorrhoid excision is often performed. This localized intervention is done under local anesthesia to remove the clot and overlying tissue. The procedure involves making a small incision and removing the entire thrombus, which leads to immediate pain relief.
After the 72-hour period, the initial peak of pain subsides, and management shifts toward conservative care. Allowing the thrombus to resolve naturally involves continued sitz baths, pain medication, and stool softeners, taking one to four weeks. However, a small flap of skin, known as a skin tag, may remain after the clot has been reabsorbed.
Criteria for Surgical Excision
A full surgical excision, or hemorrhoidectomy, is reserved for specific, complicated situations where non-surgical and office-based treatments have repeatedly failed. This includes chronic, recurrent episodes of symptomatic external hemorrhoids.
Surgery is also necessary for hemorrhoidal disease involving a significant external component mixed with advanced internal hemorrhoids, such as Grade III or Grade IV disease. Office-based procedures, like rubber band ligation, cannot adequately address this large external component. Extremely large external skin tags that interfere with hygiene or cause persistent discomfort may also warrant surgical removal.
For a thrombosed external hemorrhoid, a more formal excision may be considered if the clot is exceptionally large, or if the patient experiences severe, debilitating pain outside the 72-hour window. Definitive surgical intervention is chosen when the disease severity significantly impacts the patient’s quality of life and is unlikely to respond to less invasive methods.