Clinical Question

Are laxatives effective for the treatment of symptomatic hemorrhoids in adults?

Evidence-Based Answer

Fiber has a consistent beneficial effect in the treatment of symptomatic hemorrhoids for up to three months' follow-up as measured by overall symptoms and bleeding.

Practice Pointers

Hemorrhoid treatment options include medical management, rubber-band ligation, sclerotherapy, coagulation, and surgical hemorrhoidectomy depending on the type of hemorrhoid and the frequency and severity of symptoms. The goal of first-line medical management is to minimize constipation and associated straining. Clinical practice guidelines recommend the use of fiber despite inconclusive evidence about its effectiveness in improving symptoms.

Alonso-Coello and colleagues reviewed the literature and identified seven randomized controlled trials comparing the effectiveness of fiber versus placebo in adults 23 to 71 years of age with symptomatic hemorrhoids. The trials studied several types of fiber including ispaghula husk, Plantago ovata or psyllium, sterculia, and unprocessed bran for a treatment duration of one to 18 months. Study size ranged between 28 and 92 participants with a mean of 50. Six of the seven trials assessed the degree of improvement of individual symptoms (e.g., bleeding, pain, itching, prolapse) or overall symptoms measured at six weeks' and three months' follow-up. One study examined rubber-band ligation plus fiber versus rubber-band ligation alone for third-degree hemorrhoids (defined as hemorrhoids that prolapse with straining but are reducible) and measured recurrence rate and the need for repeat procedures at 18 months.

The results of five studies reporting overall symptoms were pooled and showed a 53 percent reduction in the risk of persistent symptoms or lack of improvement. Of those taking fiber, 16 to 40 percent did not improve compared with 23 to 61 percent of those taking placebo. The four studies that reported bleeding as an individual outcome found a trend or a significant difference in favor of the fiber group. Pooled analysis of the two studies evaluating pain or discomfort showed a nonsignificant trend in favor of fiber. Likewise, the pooled analysis of three studies showed a nonsignificant difference between fiber and placebo for persistent pro-lapse. The two studies that evaluated itching did not find a significant difference between the groups. The one study examining rubber-band ligation plus fiber versus rubber-band ligation alone reported that the number of long-term recurrences was fewer overall in the group that received fiber (15 versus 45 percent, respectively) at 18 months' follow-up.

The most common side effects with fiber were gastrointestinal symptoms, typically starting at the study onset, and these generally were not severe enough for participants to discontinue fiber. The rate of side effects varied considerably among studies, with some studies reporting no side effects and others reporting up to a 50 percent incidence of gastrointestinal bloating.

The American Gastroenterological Association recommends adequate water and fiber intake as the main-stay of medical management and suggests that topical steroids and analgesics also may be useful in relieving hemorrhoidal symptoms.¹