From the Guidelines
Treatment for internal hemorrhoids should begin with non-operative management as the first-line therapy, focusing on dietary and lifestyle changes, such as increased fiber and water intake, as well as adequate bathroom habits, as recommended by the most recent guidelines 1. This approach is supported by strong recommendations based on moderate quality evidence, emphasizing the importance of conservative measures before considering more invasive procedures. Some key aspects of non-operative management include:
- Increasing fiber intake to 25-30 grams daily
- Drinking plenty of water
- Using over-the-counter medications for symptom relief
- Topical treatments, such as Preparation H cream or suppositories containing hydrocortisone, for up to one week to reduce inflammation and discomfort
- Warm sitz baths for 10-15 minutes, 2-3 times daily, to provide significant relief
- Oral pain relievers, like acetaminophen or ibuprofen, to manage pain For persistent or severe hemorrhoids, medical procedures may be necessary, including:
- Rubber band ligation
- Sclerotherapy
- Surgical removal for very large hemorrhoids These treatments aim to reduce swelling and inflammation in the rectal veins that have become enlarged due to increased pressure, often from straining during bowel movements, prolonged sitting, chronic constipation, or pregnancy. Preventing constipation is crucial for both treatment and prevention, so maintaining regular bowel habits through proper diet and exercise is essential for long-term management, as highlighted in earlier guidelines 1.
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 internal hemorrhoids 2
- Rubber band ligation is a commonly used treatment for internal hemorrhoids, particularly for grades I to III, and has a lower failure rate than infrared photocoagulation 2, 3
- Sclerotherapy is another non-operative approach that can be used to treat internal hemorrhoids 4
Surgical Treatment Options
- Excisional hemorrhoidectomy is often reserved for recurrent or higher-grade disease, as it can be more painful and have a longer recovery time than office-based procedures 2
- Stapled hemorrhoidopexy is a surgical procedure that can be used to treat grade III or IV hemorrhoids, but it has several potential postoperative complications 2
- Hemorrhoidal artery ligation is a minimally invasive procedure that can be used to treat grade II or III hemorrhoids, and may result in less pain and faster recovery than traditional hemorrhoidectomy 2
Complications and Risks
- Rubber band ligation can be associated with complications such as mild bleeding, pain, and vaso-vagal symptoms, as well as more serious complications like massive bleeding and pelvic sepsis 3
- The use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin can increase the risk of bleeding after rubber band ligation 5
- Recurrence of symptoms after treatment is possible, but rubber band ligation can be an effective treatment for recurrent internal hemorrhoids 5