What are the treatment options for internal hemorrhoids?

From the Guidelines

Internal hemorrhoids can be effectively treated with non-operative management as the first-line therapy, focusing on dietary and lifestyle changes, such as increased fiber and water intake, and adequate bathroom habits, as recommended by the World Journal of Emergency Surgery in 2021 1.

Key Recommendations

• Increase fiber intake to 25-30 grams daily through foods or supplements like psyllium or methylcellulose.
• Drink plenty of water, 6-8 glasses daily, and avoid straining during bowel movements.
• Over-the-counter treatments like witch hazel pads, hydrocortisone creams, or combination products can reduce swelling and discomfort.
• Warm sitz baths for 10-15 minutes, 2-3 times daily, can provide relief.

Advanced Treatments

For persistent symptoms or if bleeding occurs, medical evaluation is necessary, and more advanced treatments like rubber band ligation, sclerotherapy, or surgical removal might be required for severe cases, as discussed in the American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids in 2004 1.

Considerations

• Rubber band ligation is most commonly used for first-, second-, or third-degree hemorrhoids and has a high success rate but may cause pain in some patients.
• Sclerotherapy is reserved for first- or second-degree hemorrhoids and can cause complications like pain, impotence, or urinary retention.
• The choice of treatment depends on the degree of hemorrhoids, patient's overall health, and the physician's expertise.

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 help manage symptoms 2, 3
• Office-based treatments, including rubber band ligation, are often used for grades I to III internal hemorrhoids, with a lower failure rate than infrared photocoagulation 2
• Other treatment options, such as injection sclerotherapy and bipolar electrocoagulation, may also be effective for internal hemorrhoids 4, 5

Comparison of Treatment Options

• A comparative study found that endoscopic rubber band ligation had a higher success rate than endoscopic injection sclerotherapy in terms of resolving anal protrusion, but with a higher pain score 5
• Another study found that rubber band ligation was widely used and effective in treating all grades of internal hemorrhoids 4
• The use of topical medications, particularly during the acute phase or post-operative period, can also be beneficial for patients with internal hemorrhoids 3

Surgical Options

• Open or closed (conventional) excisional hemorrhoidectomy may be necessary for recurrent or higher-grade disease, but can result in more pain and a prolonged recovery than office-based procedures 2
• Minimally invasive operations, such as Ligasure hemorrhoidectomy and stapled hemorrhoidopexy, have been introduced to reduce post-operative pain and complications 6
• Hemorrhoidal artery ligation may be useful in grade II or III hemorrhoids, with less pain and quicker recovery compared to other surgical options 2, 6