Fibre and water help haemorrhoids; the evidence for creams is thinner

Haemorrhoids are common and, for most people, treatable at home — and the best-supported measure is the least glamorous one. Haemorrhoids, also called piles, are swollen and inflamed veins around the anus or in the lower rectum, and come in two types: external, which form under the skin around the anus, and internal, which form in the lining of the anus and lower rectum [s1]. They affect about 1 in 20 Americans, and about half of adults older than age 50 have them [s1].

What raises the risk

The risk factors point straight at the mechanics of the bowel. You are more likely to get haemorrhoids if you strain during bowel movements, sit on the toilet for long periods, have chronic constipation or diarrhoea, eat foods low in fibre, are older than 50, are pregnant, or often lift heavy objects [s1]. Most of those are about pressure and about stool that is hard to pass, which is why the first-line advice is aimed at the stool rather than the vein.

The fibre evidence

The strongest randomised evidence behind that advice concerns fibre. A systematic review and meta-analysis in the American Journal of Gastroenterology pooled seven trials that randomised 378 patients to fibre or a non-fibre control [s2]. Using random-effects models, fibre showed an apparent beneficial effect: the risk of not improving or of persisting symptoms decreased by 47% (relative risk 0.53, 95% CI 0.38 to 0.73), and the risk of bleeding decreased by 50% (relative risk 0.50, 95% CI 0.28 to 0.89) [s2].

The picture for other symptoms is weaker and honestly reported. Results were also compatible with large treatment effects on prolapse, pain and itching, but even in the pooled analyses the confidence intervals were wide and compatible with no effect — relative risk 0.79 (95% CI 0.37 to 1.67) for prolapse, 0.33 (95% CI 0.07 to 1.65) for pain, and 0.71 (95% CI 0.24 to 2.10) for itching [s2]. The studies were of moderate quality for most outcomes [s2]. In other words, fibre has good evidence for the two outcomes that matter most — persisting symptoms and bleeding — and suggestive but inconclusive evidence for the rest.

What home care actually looks like

NIDDK's self-care list matches that evidence. It advises eating high-fibre foods, taking a stool softener or a fibre supplement such as psyllium (Metamucil) or methylcellulose (Citrucel), drinking water, not straining during bowel movements, not sitting on the toilet for long periods, taking over-the-counter pain relievers such as acetaminophen, ibuprofen, naproxen or aspirin, and sitting in a tub of warm water — a sitz bath — several times a day to relieve pain [s3].

Creams sit lower in the hierarchy. Over-the-counter haemorrhoid creams, ointments or suppositories may relieve mild pain, swelling and itching of external haemorrhoids, and doctors most often recommend using over-the-counter products for one week [s3]. You should follow up with a doctor if the products do not relieve symptoms after one week or cause side effects such as a rash or dry skin around the anus [s3].

When a procedure is needed

Most prolapsed internal haemorrhoids go away without at-home treatment, but severely prolapsed or bleeding internal haemorrhoids may need medical treatment [s3]. The common office procedure is rubber band ligation, in which a doctor places a band around the base of a bleeding or prolapsing internal haemorrhoid to cut off its blood supply, after which the banded part shrivels and falls off, most often within a week [s3].

External haemorrhoids can behave differently. NIDDK lists their complications as including blood clots in an external haemorrhoid, and skin tags — extra skin left behind when such a clot dissolves [s1]. A clotted, or thrombosed, external haemorrhoid is the kind that produces sudden, sharp pain rather than the ache or bleeding of the internal type, and it is worth having assessed rather than waiting out.

The honest position

The evidence favours the dull basics — more fibre, more fluid, less straining and less time on the toilet — over the products people reach for first [s2][s3]. Fibre is the one intervention with randomised support for reducing both persistent symptoms and bleeding [s2].

This article is informational and is not medical advice. Rectal bleeding should not be assumed to be haemorrhoids: it can signal other conditions, and haemorrhoid complications can include anaemia [s1]. New or persistent rectal bleeding, especially with a change in bowel habit or weight loss, needs assessment by a clinician.

Sources

• Definition & Facts of Hemorrhoids — National Institute of Diabetes and Digestive and Kidney Diseases
• Fiber for the Treatment of Hemorrhoids Complications: A Systematic Review and Meta-Analysis — The American Journal of Gastroenterology, 2006-01-01
• Treatment for Hemorrhoids — National Institute of Diabetes and Digestive and Kidney Diseases