From the Guidelines
Treatment for internal hemorrhoids should start with non-operative management as first line therapy, including dietary and lifestyle changes, as recommended by the most recent guidelines 1. For mild to moderate hemorrhoids, lifestyle changes including increasing fiber intake (25-30g daily), drinking plenty of water, and avoiding straining during bowel movements are essential.
- Over-the-counter treatments include fiber supplements like psyllium (Metamucil) or methylcellulose (Citrucel), taken with 8oz of water 1-3 times daily.
- Topical treatments such as witch hazel pads or hydrocortisone creams can provide temporary relief. For persistent symptoms, office-based procedures include:
- Rubber band ligation (placing small bands around hemorrhoid tissue to cut off circulation) 1.
- Sclerotherapy (injecting a solution to shrink hemorrhoids).
- Infrared coagulation (using infrared light to harden and shrink hemorrhoids). These procedures are minimally invasive with quick recovery times.
Surgical Options
For severe or recurring hemorrhoids, surgical options include:
- Hemorrhoidectomy (complete removal of hemorrhoids) 1.
- Stapled hemorrhoidopexy.
- Hemorrhoid artery ligation. The decision to proceed with surgical treatment should be based on local expertise and patient preference, especially in cases of thrombosed hemorrhoids 1. It's crucial to address the underlying causes of hemorrhoids, which develop when pressure increases in the lower rectum, causing veins to swell and stretch, to prevent complications like thrombosis or prolapse. Prompt treatment is essential to improve quality of life and reduce morbidity and mortality associated with internal hemorrhoids.
From the Research
Treatment Options for Internal Hemorrhoids
- Medical management, including stool softeners and topical over-the-counter preparations, is often the first line of treatment for internal hemorrhoids 2, 3.
- Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also help alleviate symptoms 3.
- Rubber band ligation is a common office-based treatment for grades I to III internal hemorrhoids, with a lower failure rate than infrared photocoagulation 3, 4.
- Excisional hemorrhoidectomy, either open or closed, may be necessary for recurrent or higher-grade disease, but it can be more painful and have a longer recovery time 2, 3.
- Stapled hemorrhoidopexy is another option for grade III or IV hemorrhoids, but it has potential postoperative complications 2, 3.
- Hemorrhoidal artery ligation may be useful for grade II or III hemorrhoids, with less pain and quicker recovery 3.
Specific Treatment Details
- Rubber band ligation has a success rate of 70.5% for symptomatic internal hemorrhoids, with similar effectiveness for all degrees of hemorrhoids 4.
- The use of acetylsalicylic acid/nonsteroidal anti-inflammatory drugs and warfarin is associated with higher bleeding rates during rubber band ligation 4.
- Infrared coagulation, bipolar electrocoagulation, and low-voltage direct current are other nonsurgical treatment options for internal hemorrhoids 5.
- Proper anal hygiene and correction of chronic constipation or diarrhea are essential to prevent recurrence of hemorrhoids 5.
Considerations for Treatment
- The choice of treatment depends on the grade of the hemorrhoid, as well as the patient's symptoms, medical history, and preferences 2, 3.
- Thrombosed external hemorrhoids can be treated conservatively or excised, depending on the severity of symptoms and the time elapsed since symptom onset 2, 3.
- Postoperative pain from excisional hemorrhoidectomy can be managed with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics 2.