Hemorrhoid suppositories: types and how to choose

Hemorrhoids aren't just "veins that need to be removed," but rather a change in the normal anal cushions. When the ligaments and fascia weaken, and straining and prolonged sitting contribute to blood stagnation, pain, itching, bleeding, and sometimes prolapse or thrombosis occur. Suppositories are needed to quickly relieve symptoms within the anal canal while you improve the key factors—soft stools and toilet habits. The American Society of Colorectal Surgeons guidelines emphasize: topical agents play a supportive role; for internal hemorrhoids with a reduced quality of life, office-based procedures (ligation, coagulation, sclerotherapy) are the preferred treatment. [1]

Understanding the "targeted" nature of the anal canal is important: a suppository acts within the anal canal, not on the skin at the anal rim. Therefore, with an external, painful "lump" and irritated skin, creams/gels are more predictable, while suppositories are reserved for internal discomfort and bleeding. If there is heavy bleeding or "red flags," the symptoms should not be attributed to hemorrhoids without an examination—this is a separate ASCRS recommendation. [2]

Another cornerstone is soft, formed stools without straining. Joint guidelines from the American Gastroenterological Association and the American College of Gastroenterology recommend polyethylene glycol (macrogol) as a first-line treatment for constipation; without this base, suppositories provide only short-term relief. [3]

Finally, time is of the essence. With external node thrombosis, the first 48-72 hours are a "window" when a minor procedure can relieve pain more quickly than waiting; after that, conservative management is usually sufficient. Suppositories in this scenario have no effect on the clot itself. [4]

Table 1. Realistic tasks of rectal suppositories for hemorrhoids

Task	What do candles do?	What not to expect from them
Relieve pain/burning inside the canal	Yes, due to the local anesthetic and emollient base	Dissolve the blood clot and eliminate prolapse
Reduce swelling and itching	Yes, with short courses of hydrocortisone	Long-term control without chair work
Make defecation easier	Yes, as a "sliding" coating	Replacements for water, fiber and osmolytics
Survive the acute period	Yes, like a "bridge"	Substitution of office methods for prolapse of II-III degree. [5]

How it works: the main classes of active ingredients in suppositories

The first and main class are local anesthetics (most commonly lidocaine, less commonly pramoxine). They block pain conduction and quickly reduce burning and itching in the root canal. This is purely symptomatic relief; the effect occurs within an hour and lasts for several hours. Lidocaine has been well studied, including its use in pregnant women in short courses. [6]

The second class is corticosteroids (usually hydrocortisone). They reduce inflammation and swelling and help with eczematization and maceration of the mucous membrane. The UK National Health Service permits hydrocortisone suppositories and ointments even during pregnancy and lactation, emphasizing their minimal systemic absorption. The course of treatment is short and at the minimum effective dose. [7]

The third block is combination agents (for example, lidocaine + anti-inflammatory component; in some countries - tribenoside + lidocaine). The presence of an anesthetic provides rapid relief; venotonics may contribute to reducing swelling, although high-quality evidence is limited. [8]

Of particular note are the “historical” anesthetics such as benzocaine: they are found in some preparations, but regulators warn of the rare, potentially severe risk of methemoglobinemia, so preference is usually given to lidocaine/pramoxine. [9]

Table 2. Active ingredients in suppositories: a brief overview

Class	What does it give?	Pros	Restrictions
Lidocaine (anesthetic)	Rapid pain relief and antipruritic effect	Well tolerated, fast onset	Symptomatic effect, short course. [10]
Hydrocortisone (steroid)	Anti-inflammatory and anti-edematous effect	Allowed during pregnancy and breastfeeding	Risk of dermatitis/atrophy with long-term use → only briefly. [11]
Tribenoside + lidocaine	Relief of pain and itching, potential venotonic contribution	Rapid improvement of symptoms	The evidence base is limited; course. [12]
Benzocaine	Anesthesia	Available in some combination forms	Rare but serious risks (methemoglobinemia) → avoid if alternatives available. [13]

What modern guides and reviews say

ASCRS (2024-2025 updates) emphasizes that rectal bleeding should not be automatically attributed to hemorrhoids, and for symptomatic internal hemorrhoids of grades II-III, office-based techniques (latex band ligation, infrared coagulation, sclerotherapy) provide better control than any suppositories. Topical therapy is for symptoms and for the duration of bowel movement. [14]

AGA/ACG (2023) recommend polyethylene glycol as a first-line treatment for "painful hard stools." This directly reduces mucosal trauma and recurrence rates. Other classes (senna/magnesium, as indicated) are added if necessary, but daily osmotics are the standard. [15]

In acute external node thrombosis, suppositories do not resolve the underlying pain. Outpatient excision provides the best pain relief in the first 48-72 hours; if treatment is delayed, a conservative approach (analgesia, sitz baths, osmotic agents) is effective. Topical creams are also indicated; data on nifedipine ointments with lidocaine show faster pain relief than lidocaine alone. [16]

During pregnancy and breastfeeding, short courses of hydrocortisone and lidocaine are permitted; UKTIS and SPS emphasize that topical preparations do not require additional fetal monitoring. The basis is non-drug measures and soft stools (macrogol/lactulose). [17]

Table 3. Where candles are appropriate and where they are not (according to the guidelines)

Situation	The role of candles	What is more important?
Discomfort inside the canal, itching, slight bleeding	Appropriate (lidocaine ± short steroid)	Soft stool, "short visit" hygiene. [18]
Internal nodes II-III with prolapse	Auxiliary	Office techniques after examination. [19]
External painful "lump" (suspected thrombosis)	Second time	Early excision ≤ 48-72 h or conservative management. [20]
Pregnancy/lactation	Briefly acceptable	Macrogol/lactulose, baths, care; vasoconstrictors are not the first line. [21]

How to choose suppositories based on your symptoms: a practical guide without brands

If the primary complaint is burning/pain within the canal, lidocaine suppositories are a logical first choice. If there is severe inflammation and itching, hydrocortisone is added briefly, followed by barrier care (rinsing, gentle drying, and a neutral barrier cream). [22]

If the primary problem is hard stool and anxiety about defecation, the primary "analgesic" measure is daily polyethylene glycol, water, and fiber. Glycerin suppositories can be used occasionally as an "accelerator," but they do not replace the base. During pregnancy, docusate sodium can be used "on demand." [23]

If there is blood on the paper without severe pain, a doctor's evaluation is needed (to rule out a crack or other causes). In this scenario, suppositories are a bridge to comfort until a decision is made about an examination and, if indicated, a procedure. [24]

If the pain is external (skin at the edge of the anus), suppositories are inferior to creams. For a thrombosed external node, it is important to "catch" the 48-72 hour window for outpatient excision; otherwise, conservative treatment is recommended. [25]

Table 4. Symptom → first line → what to add

Symptom	First line	What to add
Burning/pain inside	Lidocaine suppositories	Short course of hydrocortisone → barrier care. [26]
Dry stool, pain during defecation	Polyethylene glycol daily	Occasionally - glycerin; monitor water/fiber intake. [27]
Blood on paper	Diagnosis + stool correction	Candles temporarily, according to symptoms. [28]
Pain outside/"lump"	Lidocaine cream, baths	Early excision in case of thrombosis; suppositories are not a priority. [29]

How to Use Candles Properly: Technique, Courses, and Common Mistakes

The suppository is inserted after hygiene (washing with warm water without soap, blotting dry), preferably at night. During the acute phase, lidocaine suppositories are acceptable 1-2 times a day; if hydrocortisone is added, the course should be short (usually days, not weeks), followed by only care and a base for bowel movements. [30]

Avoid "layering" your products: don't use several suppositories of different classes in a row—it's better to alternate them (for example, lidocaine at night, then just the care product in the morning). Any increase in burning, rash, or bleeding is a reason to stop using the product and discuss an alternative. [31]

For external symptoms and dermatitis around the anus, suppositories are less effective than creams, as the application point is different. This is a common mistake, leading patients to "change suppositories" for weeks without seeing any results. [32]

Separately - about benzocaine: if it is included in the composition, take into account the rare, but described risk of methemoglobinemia; if possible, choose lidocaine forms. [33]

Table 5. "Safety Rules" and Typical Mistakes

Rule/Error	Why is it important?	What to do
Short steroid courses	Reducing the risk of atrophy/dermatitis	After the swelling has subsided, proceed to care. [34]
Addressability of the application point	The candle acts internally, not on the skin.	For external pain - cream/gel with anesthetic. [35]
A chair base is required.	Without it, the pain and bleeding return.	Polyethylene glycol daily, water, fiber. [36]
Caution with benzocaine	Rare but serious risks	Prefer lidocaine. [37]

Special groups: pregnancy and breastfeeding

During pregnancy and lactation, rectal hydrocortisone and lidocaine are considered acceptable for short courses and minimally sufficient doses. The NHS emphasizes minimal systemic absorption; SPS/UKTIS - there is no basis for additional fetal monitoring due to the topical agents themselves. The basis is non-drug measures and soft stools (macrogol, lactulose); docusate is acceptable as needed. [38]

Vasoconstrictor components (phenylephrine and similar compounds) have a limited safety profile during pregnancy and are not considered first-line therapy. The decision regarding such formulations should be made by a physician. [39]

If atypical symptoms appear while taking suppositories (increasing pain, swelling, heavy bleeding, weakness, dizziness) - this is a reason to immediately consult a doctor, and not “intensify the course.” [40]

Table 6. “Green List” for pregnant and lactating women (by active ingredients)

Class	Status	Comment
Lidocaine	Let's put it briefly	Minimum sufficient frequency, proper hygiene. [41]
Hydrocortisone	Let's put it briefly	A course of days, then care; not “for months.” [42]
Osmotics (macrogol, lactulose)	First line	Base for the prevention of straining. [43]
Docusat	Let's assume	Occasionally as needed. [44]

A Two-Week Plan: How to Combine Candles, Stool, and Care

Days 1-3. Start with a base regimen: daily polyethylene glycol, water, and fiber; a quick trip to the toilet with a footrest; warm sitz baths for 10-15 minutes 2-3 times daily. Based on symptoms, use lidocaine suppositories at night; if inflammation is severe, add a short course of hydrocortisone. [45]

Days 4-7. Assess the effect: if it's better, switch to "as needed"; if bleeding/loss persists, schedule an examination (in-office procedures are possible). External pain? Switch to creams; if thrombosis is suspected, consult a doctor immediately (early excision is possible). [46]

Days 8-14. Maintain a base for bowel movements. If symptoms persist, do not increase the steroid dose—return to care and discuss tactics. If necessary, schedule office interventions (ligation, etc.). [47]

Table 7. "If... then..." - a pocket map for 2 weeks

If	That
It burns and hurts inside	Lidocaine suppositories in brief + baths + base for stool
Dry stool, pain when passing stool	Polyethylene glycol daily; glycerin occasionally
Bleeding/loss persists	Review and discussion of office techniques
Pain on the outside or "blue bump"	Anesthetic cream; exclude thrombosis, consider excision (≤ 72 h)

FAQ: Short answers to frequently asked questions

Will suppositories "cure" hemorrhoids?
No. They alleviate symptoms within the canal. For prolapse and recurrences, in-office treatments are more effective, and the foundation is soft stool. [48]

Which suppositories should you try first?
Look for lidocaine as the active ingredient; for severe inflammation, try hydrocortisone briefly. Avoid long courses and benzocaine-containing formulations if alternatives are available. [49]

Are suppositories necessary if the pain is external?
Rarely. Creams/gels are more effective for the skin around the anus; if thrombosis of an external node is suspected, a doctor decides (sometimes early excision is recommended). [50]

Are suppositories safe during pregnancy?
Hydrocortisone and lidocaine are acceptable for short periods; stool preparations should be based on macrogol/lactulose. Topical preparations do not require additional fetal monitoring. [51]