An otherwise healthy 42-year-old man has three episodes of small-volume, painless, bright red rectal bleeding during defecation over the past two days. External examination shows protrusion of tissue at the anal verge without thrombosis or strangulation; internal exam shows no fluctuance and normal sphincter tone. Which of the following is the most appropriate management?

• A. Topical Hydrocortisone
• B. Anal fissure drainage
• C. Immediate hemorrhoidectomy
• D. Laxatives

Answer: (A)

Painless bright red bleeding with a protruding anal tissue that’s not strangulated or inflamed points to hemorrhoids, specifically a prolapsed internal hemorrhoid, rather than an acute fissure or an infectious process. When there’s prolapse without thrombosis or signs of infection, the best first step is conservative symptom control. Topical hydrocortisone reduces anal mucosal inflammation and itching, helping with the irritation and swelling from hemorrhoids. It’s a safe, effective first-line measure in this setting, especially alongside measures to soften stools and prevent straining, such as a high-fiber diet and adequate fluids (with or without stool softeners).

Anal fissure drainage isn’t indicated here because fissures typically present with sharp, severe pain during and after defecation, not a painless prolapse with mild bleeding. Immediate hemorrhoidectomy isn’t needed for uncomplicated prolapsed hemorrhoids, as surgery is reserved for refractory cases or complications. Laxatives alone don’t address the inflammatory symptoms and aren’t a complete management strategy by themselves, though they can be part of a broader plan to reduce straining.