Laxatives for the treatment of hemorrhoids

Symptomatic hemorrhoids are a common medical condition but what causes them is not completely understood. Minimizing constipation with its associated prolonged straining may affect both lifestyle measures and medicines used as treatments for symptomatic hemorrhoids.
This systematic review suggests a beneficial effect of laxatives in the form of fiber for improving symptoms of hemorrhoids, especially bleeding. The improvement, halving the risk of having overall symptoms, was consistent over up to three months follow up. The results for other symptoms such as prolapse, pain or itching were not clear from the included trials.
The relatively small number of patients enrolled in trials to date could argue for the need for additional larger trials.

Authors' conclusions: 

The use of fiber shows a consistent beneficial effect for relieving overall symptoms and bleeding in the treatment of symptomatic hemorrhoids.

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Background: 

Symptomatic hemorrhoids are a common medical condition, which increase in prevalence in women during pregnancy and postpartum. Although the evidence appears to be inconclusive, narrative reviews and clinical practice guidelines recommend the use of laxatives (and fiber) for the treatment of hemorrhoids and relief of symptoms. This is due to their safety and low cost.

Objectives: 

To evaluate the impact of laxatives on a wide range of symptoms in people with symptomatic hemorrhoids.

Search strategy: 

Search strategy
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library Issue 2, 2005), MEDLINE (1966 to 2005), EMBASE (1980 to 2005), CINAHL (1982 to 2005), BIOSIS, and AMED (Allied and Alternative Medicine Database), for eligible trials (including conference proceedings).
We sought missing and additional information from authors, industry, and experts in the field.

Selection criteria: 

We selected all published and unpublished randomised controlled trials that compared any type of laxative to placebo or no therapy in any patient population.

Data collection and analysis: 

Two authors independently screened studies for inclusion and retrieved all potentially relevant studies. Data were extracted from studies that met our selection criteria on study population, intervention used, pre-specified outcomes, and methodology. We extracted methodological information for the assessment of internal validity: existence and method of generation of the randomization schedule, and method of allocation concealment; blinding of caregivers and outcomes assessors; numbers of and reasons for participants lost to follow up; and use of validated outcome measures.

Main results: 

Seven randomised trials enrolling a total of 378 participants to fiber or a non-fiber control were identified. Meta-analyses using random-effects models showed that laxatives in the form of fiber had a beneficial effect in the treatment of symptomatic hemorrhoids. The risk of not improving hemorrhoids and having persisting symptoms decreased by 53% in the fiber group (risk reduction (RR) 0.47, 95% CI 0.32 to 0.68). These results are compatible with large treatment effects regarding prolapse, pain, itching, although the pooled analyses showed a tendency toward no-effect for these parametres.
The effect on bleeding showed a significant difference in favour of the fiber (RR 0.50, 95% CI 0.28 to 0.89).
Studies including data on multiple follow ups (usually after six weeks and three months) showed consistent results over time.
However, we have to stress two possible limitations of this review: the risk of publication bias, and only moderate study quality.

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