From the Guidelines
Treatment for internal hemorrhoids should start with non-operative management as first line therapy, including dietary and lifestyle changes, such as increased fiber and water intake, and adequate bathroom habits, as recommended by the most recent guidelines 1.
Overview of Treatment Options
Treatment options for internal hemorrhoids range from conservative measures to medical and surgical interventions. The goal of treatment is to reduce symptoms, improve quality of life, and minimize the risk of complications.
Conservative Measures
For mild to moderate hemorrhoids, conservative measures are often effective. These include:
- Increasing fiber intake to 25-30g daily
- Drinking plenty of water
- Avoiding straining during bowel movements
- Using over-the-counter fiber supplements like psyllium (Metamucil) at 1 teaspoon 1-3 times daily
- Using stool softeners such as docusate sodium (100mg twice daily)
- Applying topical treatments containing hydrocortisone or witch hazel to reduce inflammation and discomfort
- Taking warm sitz baths for 10-15 minutes, 2-3 times daily
Office-Based Procedures
For more severe or persistent hemorrhoids, office-based procedures may be necessary. However, there is no recommendation for the use of office-based procedures, such as rubber band ligation, sclerotherapy, or infrared coagulation, in complicated hemorrhoids, due to the lack of high-quality evidence 1.
Surgical Options
Surgical options, such as hemorrhoidectomy, stapled hemorrhoidopexy, or hemorrhoid artery ligation, are typically reserved for severe cases, including large third-degree or fourth-degree hemorrhoids, acutely incarcerated and thrombosed hemorrhoids, or patients who have undergone less aggressive therapy with poor results 1.
Prioritizing Patient Care
When treating internal hemorrhoids, it is essential to prioritize patient care, focusing on reducing morbidity, mortality, and improving quality of life. The most recent and highest quality study recommends non-operative management as the first line of treatment, with a strong recommendation based on moderate quality evidence 1. By following this approach, healthcare providers can provide effective and patient-centered care for individuals with internal hemorrhoids.
From the Research
Treatment Options for Internal Hemorrhoids
- Medical therapy can be initiated with stool softeners plus local therapy to relieve swelling and symptoms 2
- Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids, causing less postoperative pain and fewer complications than excisional hemorrhoidectomy and stapled hemorrhoidopexy, but has a higher recurrence rate 2
- For grade 3 hemorrhoids, rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed 2
- Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids 2
- Low-graded internal hemorrhoids can be effectively treated with medication and non-operative measures such as rubber band ligation and injection sclerotherapy 3
- Surgery is indicated for high-graded internal hemorrhoids, or when non-operative approaches have failed, or complications have occurred 3
- Traditional hemorrhoidectomy is the best definitive treatment for prolapsed internal hemorrhoids 4
- Rubber band ligation produces the lowest rate of recurrence among nonoperative techniques 4
- Band ligation is the best management option for persistently bleeding or painful internal hemorrhoids 5
- The CRH-O'Regan banding device is an emerging technology for the anoscopic treatment of symptomatic internal hemorrhoids 6
Non-Surgical Management
- Dietary changes, stool softeners, and local hydrocortisone creams can be used for conservative management of hemorrhoids 5
- Nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics can be used to treat postoperative pain from excisional hemorrhoidectomy 2
Surgical Interventions
- Excisional hemorrhoidectomy remains the mainstay operation for advanced hemorrhoids and complicated hemorrhoids 3
- Minimally invasive operations such as Ligasure hemorrhoidectomy, doppler-guided hemorrhoidal artery ligation, and stapled hemorrhoidopexy have been introduced to avoid post-hemorrhoidectomy pain 3