Treatment of external hemorrhoid thrombosis includes observation or excision, but excision completed within 48 to 72 hours of symptom onset can result in rapid resolution of symptoms. (Level of Evidence 4, Recommendation Level B). External hemorrhoid thrombosis can form spontaneously or secondary to stool earning or weight lifting. The exact pathogenesis is unclear. There is very little scientific material comparing treatment options for thrombosed external hemorrhoids. Clinical experience recommends that external hemorrhoidectomy under local anesthesia is best for cases with symptoms occurring within 48 to 72 hours. Thrombosis beyond 72 hours can wait for as treatment if the pain is not severe, avoiding constipation, pain relief, icing, or sitz baths can provide more rapid symptom relief than surgery. Simple incision to remove the clot should be avoided because the typical lesion is an embolism of multiple small vessels rather than a single clot, and simple incision often causes a recurrence of the original site of the clot or even spreads into a ring of hemorrhoidal embolism.