Conservative Treatment Options
Patient Information Sheet
Anal Creams, Ointments & Suppositories
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Why Conservative Treatments Appear to Work
Hemorrhoidal symptoms often have a waxing and waning course. Symptoms may improve spontaneously regardless of treatment. Because of this natural fluctuation, many topical treatments appear effective, even when their true therapeutic benefit is limited.
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Commonly Used Creams and Ointments
A wide range of products are commonly used, including anesthetic creams, vasoconstrictors, astringents, steroid-containing preparations, and so-called natural or homeopathic remedies. While some provide short-term symptom relief, none have been shown to alter the underlying disease process.
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Hydrocortisone Creams: Benefits and Risks
Topical corticosteroids such as hydrocortisone may provide short-term relief of itching and inflammation.
However, prolonged or repeated use is associated with thinning of the perianal skin and mucosa, skin fragility, and worsening irritation. Long-term steroid use in the perianal region has been linked to chronic symptoms such as pruritus ani, skin atrophy, and delayed healing. For this reason, steroid-containing creams should be used sparingly and for limited durations only.
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Suppositories
Suppositories are commonly prescribed for hemorrhoidal symptoms, yet evidence supporting their effectiveness is limited. As most hemorrhoids arise from the anal canal rather than the rectum, suppositories often fail to adequately treat the affected tissue.
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Key Take-Home Points
Symptom improvement often reflects the natural course of hemorrhoids rather than treatment effect. Topical agents may provide temporary relief but do not cure hemorrhoids. Prolonged steroid use can worsen long-term perianal symptoms. Conservative measures should focus on bowel habits, fiber intake, and avoidance of straining
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Selected Evidence & Literature
MacRae HM, McLeod RS. Comparison of hemorrhoidal treatments. Br J Surg. Limited evidence for topical agents beyond short-term symptom relief.
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Acheson AG, Scholefield JH. Management of hemorrhoids. BMJ. Topical steroids associated with skin atrophy when used long-term.
Loder PB et al. Hemorrhoids: pathology, pathophysiology, and etiology. Br J Surg. Symptoms often fluctuate regardless of intervention.
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This handout is for patient education and does not replace individualized medical advice.
Fiber Supplementation & Bowel Control
Why Bowel Control Matters?
If bowel movements were perfectly regulated in everyone, hemorrhoids would be uncommon. In reality, constipation, straining, irregular stools, and prolonged time on the toilet are major contributors to hemorrhoidal disease. For this reason, controlling stool consistency and bowel habits is the single most important step in both preventing and treating hemorrhoids.
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Most People Do Not Get Enough Fiber
Despite common beliefs, most people do not consume enough dietary fiber. This remains true even for
individuals who consider their diet to be healthy, vegetarian, or vegan. Population studies consistently show that average daily fiber intake falls well below recommended levels. The Institute of Medicine recommends approximately 25–38 grams of fiber per day depending on age and sex, yet average intake in North America is often less than half of this amount.
Why Fiber Supplements Are Helpful?
Because it is difficult to consistently meet fiber targets through diet alone, fiber supplementation is often necessary. The specific type of fiber is less important than regular, consistent use. In practice, the best fiber is the one you tolerate and will take daily.
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Which Fiber Should You Use?
Many fiber options are effective, including ground flaxseed, wheat fiber, chia seeds, psyllium (e.g., Metamucil), and other commercial fiber products. Dosing should be appropriate for body weight and adjusted gradually to minimize bloating.
Soluble fibers are particularly helpful. Inulin (Iâ– Nâ– Uâ– Lâ– Iâ– N), found in products such as Benefiber, is easy to incorporate into daily routines and works well alongside other fiber sources. Inulin also acts as a prebiotic, supporting healthy gut bacteria. Please see our separate handout on prebiotics for more information.
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Key Take-Home Points
Stool consistency matters more than stool frequency
Most people require fiber supplementation despite a healthy diet
The best fiber is the one you will take every day
Combine fiber supplementation with adequate fluids and healthy eating
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Selected Evidence & Literature
Institute of Medicine. Dietary Reference Intakes for Fiber: most adults do not meet recommended intake levels.
Alonsoâ– Coello P et al. Fiber for the treatment of hemorrhoids. Cochrane Review. Fiber reduces bleeding and improves
symptoms.
Slavin JL. Fiber and prebiotics: mechanisms and health benefits. Nutrients.
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This handout is for patient education and does not replace individualized medical advice.
Bowel Habits part 2
Straining, and Toilet Behaviour
Why Bowel Habits Matter
If bowel movements were consistently soft and passed without straining, hemorrhoids would be far less common. In reality, straining, hard stools, and prolonged time on the toilet are the primary contributors to hemorrhoidal disease. Improving bowel habits is therefore one of the most important steps in preventing and treating hemorrhoids.
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What Hemorrhoids Are Designed to Do
Hemorrhoids are normal, highly elastic blood vessels within the anal canal. They are designed to swell slightly when you bear down in order to protect the anal sphincter muscles during bowel movements. Under normal circumstances, this swelling is temporary and harmless. Problems arise when there is repeated or prolonged straining, or when very hard or bulky stools pass through the anal canal. This leads to persistent engorgement, stretching, and eventual prolapse of the hemorrhoidal tissue.
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Straining Should Be Avoided at All Costs
Repeated straining is one of the most important factors in the development and progression of hemorrhoids. Straining increases pressure within the hemorrhoidal columns, causing them to enlarge, stretch, and become symptomatic. Avoiding straining is critical to long-term symptom control.
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Practical Toilet Habits That Help
Simple changes in toilet behaviour can significantly reduce strain and pressure on the hemorrhoidal tissue.
Use a small footstool or bench to elevate your feet while sitting on the toilet. This changes the angle of the rectum and allows stools to pass more easily. Avoid sitting on the toilet for prolonged periods of time. Do not read, browse your phone, or spend unnecessary time on the toilet. If nothing happens after a few minutes, get up and try again later.
A Simple Rule
The toilet should be used for bowel movements only, not as a place to sit, read, or scroll on a phone. Leaving your phone outside the bathroom is a surprisingly effective way to reduce prolonged straining.
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Part of a Larger Plan
Healthy bowel habits work best when combined with adequate fiber intake, proper hydration, and attention to stool consistency. Additional guidance on bowel habits and conservative management will be addressed in future patient education materials.
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This handout is for patient education and does not replace individualized medical advice.
How Often Should You Have a Bowel Movement?
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A Common Question
A frequent question in clinic is: How many bowel movements are normal? Many patients report having only one or two bowel movements per week. This pattern is not normal and commonly contributes to hemorrhoidal disease.
Why Infrequent Bowel Movements Cause Problems
When bowel movements are infrequent, stool often becomes hard and dry. The first part of the bowel movement is typically large and difficult to pass, which stretches and damages the anal canal and hemorrhoidal tissue. This is often followed by loose stool or diarrhea, creating a cycle of injury and irritation.
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The Gastrocolic Reflex
The human body is designed to move the bowels regularly through a mechanism called the gastrocolic reflex. After eating, the stomach signals the colon to contract, moving stool toward the rectum and creating the urge to have a bowel movement. This is a normal and healthy response. This reflex is easily observed in infants: feeding is often followed shortly by a bowel movement. Over time, social pressures and daily routines train many adults to ignore this natural urge.
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What Is an Ideal Bowel Movement Pattern?
From a physiological point of view, an ideal bowel pattern is a bowel movement in response to meals. For many people, this means one bowel movement per meal, up to three bowel movements per day. This pattern is normal, healthy, and protective for the anal canal and hemorrhoidal tissue.
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Ignoring the Urge Has Consequences
Repeatedly suppressing the urge to have a bowel movement leads to irregular bowel habits, larger and harder stools, and increased straining. This pattern is commonly seen in Western societies and is far less common in regions where bowel habits follow natural rhythms.
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Key Take-Home Points
One to two bowel movements per week is not normal for most people.
One bowel movement per meal, up to three per day, is physiologically normal.
Infrequent stools lead to hard, damaging bowel movements.
Responding to natural urges protects the hemorrhoidal tissue.
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This handout is for patient education and does not replace individualized medical advice.
Oral Venoactive Medications (Flavonoids)
What Are Oral Venoactive Medications?
Some oral medications used for hemorrhoids act on the venous (vascular) system rather than directly on stool or bowel habits. The most commonly studied agent is Micronized Purified Flavonoid Fraction (MPFF), which is composed mainly of diosmin and hesperidin. In Canada, these products are most commonly referred to as diosmin-based medications or supplements. Internationally, they are often known by brand names such as Daflon.
How Do They Work?
These medications are thought to improve venous tone, reduce capillary permeability, and decrease venous congestion and inflammation. Because hemorrhoids are dilated venous cushions, this mechanism may reduce symptoms during acute flare-ups.
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What Does the Evidence Show?
Clinical studies and systematic reviews suggest that MPFF may reduce bleeding and discomfort, particularly in acute hemorrhoidal episodes. However, the overall effect is modest and primarily symptomatic. These medications do not correct prolapse or structural hemorrhoidal disease. Long-term outcomes are inferior to office-based procedures such as hemorrhoidal banding, and symptom recurrence is common once the medication is stopped.
Our Practical View
In our experience, oral venoactive medications do not replace the fundamentals of hemorrhoid management, including stool regulation, fiber supplementation, and healthy bowel habits. If these core conservative measures are not effective, oral flavonoids are also unlikely to be effective on their own. For patients with persistent symptoms or prolapsing hemorrhoids, definitive treatments such as office-based procedures are generally more effective.
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Where This Fits in Treatment
Oral venoactive medications may be considered as an adjunct in selected patients, particularly during acute flare-ups. They should be viewed as supportive therapy rather than definitive treatment.
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Selected Evidence and Literature
Alonso-Coello P et al. Cochrane Review: dietary fiber and conservative measures remain first-line therapy.
Shanmugam V et al. Systematic review: flavonoids improve short-term symptoms but do not address prolapse.
European and international colorectal guidelines: MPFF as adjunctive therapy, not definitive treatment.
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This handout is for patient education and does not replace individualized medical advice.
Bowel Movements and Vaginal Pressure (“Splinting”)
A Common and Understandable Maneuver
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A Common Question
Some patients report that they need to press with a finger inside the vagina or against the vaginal wall to help pass stool. This is a very common maneuver and is something many women discover naturally over time.
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Why This Happens
This maneuver is often related to a condition called a rectocele. A rectocele occurs when the wall between the rectum and the vagina becomes weakened, allowing stool to bulge forward into the vaginal space during bowel movements.
In early or mild cases, this bulging can interfere with stool passage. Applying gentle pressure to the vaginal wall can help support the rectum and allow stool to pass more easily.
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Is This Safe?
Yes. Using gentle vaginal pressure to assist with bowel movements is generally safe and can be continued if it helps. This maneuver is not harmful and does not worsen the condition. Patients should avoid excessive straining and continue to focus on stool softness, fiber supplementation, and healthy bowel habits.
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When Should You Seek Further Assessment?
If this maneuver is required frequently, if symptoms worsen, or if there is a sensation of pelvic pressure or bulging, further assessment is appropriate. At the clinic, we can evaluate for rectocele and other pelvic floor conditions. If needed, we are happy to provide advice, initiate conservative management, or refer you to an appropriate pelvic floor or colorectal surgeon for further treatment.
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This handout is for patient education and does not replace individualized medical advice.
Pelvic Floor Dyssynergia
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What Is Pelvic Floor Dyssynergia?
Pelvic floor dyssynergia is a condition in which the muscles of the pelvic floor do not relax appropriately during a bowel movement. Instead of opening to allow stool to pass, these muscles may tighten or contract, making evacuation difficult or incomplete.
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Why Does This Cause Symptoms?
A normal bowel movement requires coordination between rectal contraction and pelvic floor relaxation. In pelvic floor dyssynergia, this coordination is disrupted. As a result, patients may experience difficulty initiating bowel movements, a sensation of incomplete emptying, excessive straining, and worsening hemorrhoidal symptoms.
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How Common Is This?
Pelvic floor dyssynergia is more common than generally recognized and is frequently underdiagnosed. It often coexists with constipation and hemorrhoidal disease.
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Treatment Options
Most cases can be treated conservatively. First-line treatment includes pelvic floor physiotherapy, often using biofeedback techniques to retrain muscle coordination and relaxation. This approach is effective for many patients.
Additional treatment options may include stool regulation strategies, education on proper bowel mechanics, and, in selected cases, medications to reduce muscle spasm or improve bowel coordination.
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Why Identification Matters
If pelvic floor dyssynergia is present, treatments focused only on stool softness or hemorrhoids may be less effective. Addressing this condition can significantly improve symptoms and reduce the need for repeated procedures.
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Our Approach
If pelvic floor dyssynergia is suspected, we can assess this during your clinic visit, provide guidance on conservative management, and refer you to experienced pelvic floor physiotherapists when appropriate.
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This handout is for patient education and does not replace individualized medical advice.