From the Guidelines
Treatment for internal hemorrhoids typically begins with conservative measures like increasing fiber intake to 25-30 grams daily, drinking plenty of water, and using over-the-counter medications, as recommended by the American Gastroenterological Association 1.
Initial Treatment
For mild symptoms, the following can be tried:
- Topical treatments such as Preparation H or hydrocortisone cream applied up to four times daily for no more than one week
- Oral pain relievers like acetaminophen or ibuprofen to help manage discomfort
- Sitz baths (warm water soaks) for 15 minutes, 2-3 times daily, to provide significant relief If these approaches don't work after 1-2 weeks, medical procedures may be necessary.
Medical Procedures
The following medical procedures can be considered:
- Rubber band ligation, which is most commonly used for first-, second-, or third-degree hemorrhoids, with a success rate of up to 80% 1
- Sclerotherapy, which can be used for smaller hemorrhoids
- Surgical removal, which is usually reserved for severe cases, such as symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids 1
Prevention of Recurrence
Maintaining regular, soft bowel movements is crucial for both treatment and prevention of recurrence. This can be achieved by:
- Increasing fiber intake to 25-30 grams daily
- Drinking plenty of water
- Avoiding straining during bowel movements
- Avoiding prolonged sitting
- Managing chronic constipation
- Avoiding pregnancy-related complications
Complications and Risks
The most common complication of rubber band ligation is pain, which is reported in 5%–60% of treated patients 1. Other complications, such as abscess, urinary retention, band slippage, prolapse and thrombosis of adjacent hemorrhoids, and minor bleeding from the ulcer, occur in 5% of patients. Severe bleeding occasionally requires intervention when the eschar from the band sloughs, usually 1–2 weeks after treatment. Necrotizing pelvic sepsis is a rare complication of rubber band ligation.
From the Research
Treatment Options for Internal Hemorrhoids
- Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the first line of treatment for internal hemorrhoids 2
- Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also be effective in managing symptoms 2
- If these initial treatments are unsuccessful, office-based procedures like rubber band ligation can be used to treat grades I to III internal hemorrhoids, with a lower failure rate than infrared photocoagulation 2
- For more severe or recurrent cases, surgical options like open or closed excisional hemorrhoidectomy, stapled hemorrhoidopexy, or hemorrhoidal artery ligation may be considered 2, 3
- The choice of treatment depends on various factors, including the grade of the hemorrhoid, patient preference, and the presence of comorbidities 2
Surgical Procedures
- Open or closed excisional hemorrhoidectomy can lead to greater surgical success rates, but may result in more pain and a prolonged recovery 2
- Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain 2
- Stapled hemorrhoidopexy can elevate grade III or IV hemorrhoids to their normal anatomic position, but has potential postoperative complications 2
- Hemorrhoidal artery ligation may be a useful option for grade II or III hemorrhoids, with less pain and quicker recovery 2