# Pediatric external hemorrhoids: clinical characteristics and outcomes of conservative treatment versus injection sclerotherapy

## TL;DR

This study compares conservative treatment and injection sclerotherapy for pediatric external hemorrhoids, finding both effective but with different risks and outcomes.

## Contribution

The study highlights the value of parent-provided photographs in diagnosing intermittent pediatric external hemorrhoids and compares treatment efficacy and risks.

## Key findings

- Parent-provided photographs confirmed diagnosis in 63.6% of cases due to intermittent symptoms.
- Injection sclerotherapy had a 90.3% success rate after two treatments but caused complications in 35.5% of patients.
- Conservative management resolved symptoms within a year but left lesions unresolved.

## Abstract

Pediatric external hemorrhoids are rare and often misdiagnosed. This study assesses clinical presentation, risk factors, and treatment outcomes, comparing conservative management with injection sclerotherapy. A retrospective cohort study (2007–2024) was conducted at a tertiary pediatric hospital, including pediatric patients treated with conservative therapy (watchful waiting) or injection sclerotherapy for external hemorrhoids. Data from medical records were analyzed for patient history, presentation, treatment outcomes, and complications. Forty-four patients (86.4% male) were included. Mean age at symptom onset and presentation was respectively 4.0 (range 0–11) and 5.8 (range 2–13) years, with a median diagnostic delay of 20.5 months. All reported anal protrusion/swelling during/after defecation, though this was only visible on examination in 11.4%; diagnosis was otherwise based on parent-provided photographs (63.6%) or reference images (25.0%). Additional symptoms included pain (45.5%), bleeding (18.2%), anal itching (13.6%), anxiety (9.1%) and tenesmus (6.8%). Thirty-one patients (70.5%) underwent injection sclerotherapy, with a 69.2% success rate after one, and 90.3% after two injections. Thirteen patients (29.5%) were treated conservatively with watchful waiting, with symptoms resolving within one year, although the lesion(s) persisted. Skin erosion occurred in 35.5% of patients treated with injection sclerotherapy, leading to constipation and defecation anxiety in 9.1% of patients.

Conclusion: Pediatric external hemorrhoids present as anal protrusion/swelling, often accompanied by anorectal pain. Diagnosis is often delayed due to its intermittent nature. Parent-provided photographs can confirm diagnosis. Both conservative management and injection sclerotherapy are viable treatments; injection sclerotherapy offers a definitive resolution but carries risks of relapse and complications.
What is Known:• Pediatric external hemorrhoids are often misdiagnosed and mismanaged.What is New:• Due to the intermittent nature of external hemorrhoids, diagnosis is often delayed, making parent-provided photographs highly valuable for accurate assessment.• Both conservative management and injection sclerotherapy are viable treatments.• Injection sclerotherapy carries risks of relapse and complications.

What is Known:

• Pediatric external hemorrhoids are often misdiagnosed and mismanaged.

What is New:

• Due to the intermittent nature of external hemorrhoids, diagnosis is often delayed, making parent-provided photographs highly valuable for accurate assessment.

• Both conservative management and injection sclerotherapy are viable treatments.

• Injection sclerotherapy carries risks of relapse and complications.

The online version contains supplementary material available at 10.1007/s00431-025-06392-2.