What is the treatment for internal hemorrhoids?

Treatment of Internal Hemorrhoids

For internal hemorrhoids, first-line treatment should be non-operative management with dietary and lifestyle changes including increased fiber and water intake along with adequate bathroom habits. 1

Classification of Internal Hemorrhoids

Internal hemorrhoids are classified according to their symptoms:

• First-degree: Bleed but do not protrude
• Second-degree: Protrude with defecation but reduce spontaneously
• Third-degree: Protrude and require digital reduction
• Fourth-degree: Cannot be reduced 1

Treatment Algorithm Based on Hemorrhoid Grade

First-Line Treatment (All Grades)

• Dietary modifications:

  • Increased fiber intake (psyllium has been shown to reduce hemorrhoidal bleeding and painful defecation) 1
  • Increased water intake
  • Avoidance of straining during defecation 1

• Pharmacological options:

  • Flavonoids to relieve symptoms (weak recommendation based on moderate quality evidence) 1
  • Topical muscle relaxants for thrombosed or strangulated hemorrhoids 1
  • Topical analgesics may provide symptomatic relief of pain and itching 1
  • Anti-motility agents if diarrhea is exacerbating symptoms 1

Second-Line Treatment (Based on Grade)

Grade I and II Hemorrhoids

• Sclerotherapy: Submucosal injection of sclerosing agents (5% phenol in oil, 5% quinine and urea, or hypertonic salt solution)
  • Success rate: 89.9% improvement or cure 1
  • Complications: Pain (12-70% of patients), potential for impotence, urinary retention, abscess 1

Grade I, II, and III Hemorrhoids

• Rubber band ligation: Most effective office-based procedure 2
  • Lower recurrence rate compared to other non-operative techniques 1
  • May cause more discomfort than other techniques, but pain is usually minor 1
  • Caution: Increased risk of severe infection in immunocompromised patients 1

Grade III and IV Hemorrhoids

• Surgical hemorrhoidectomy: Most effective treatment but associated with more pain and complications 1
  • Indications:
    • Failure of medical and non-operative therapy
    • Symptomatic third-degree, fourth-degree, or mixed hemorrhoids
    • Symptomatic hemorrhoids with concomitant anorectal conditions 1

Special Considerations

Thrombosed Hemorrhoids

• For thrombosed external hemorrhoids, early excision under local anesthesia (ideally within 72 hours of symptom onset) is optimal management 2
• For thrombosed internal hemorrhoids, consider topical muscle relaxants 1
• If symptoms are already resolving, excision is not required as pain typically resolves after 7-10 days 1

Prolapsed and Strangulated Hemorrhoids

• Initial management: Stool softeners, analgesics, rest, warm soaks, and ice packs until recovery
• Later management: Banding or excision of residual hemorrhoids 2

Important Caveats

• Rectal bleeding evaluation: All patients who report rectal bleeding should undergo sigmoidoscopy. For patients with risk factors for colorectal cancer (age >50, family history, personal history of polyps), colonoscopy or air-contrast barium enema should be performed to rule out more serious conditions 1

• Corticosteroid use: While corticosteroid creams may help with perianal inflammation, there's no evidence they reduce hemorrhoidal swelling, bleeding, or protrusion. Long-term use of high-potency corticosteroid preparations is harmful and should be avoided 1

• Complications of procedures: Be aware that rubber band ligation, while effective, can rarely lead to severe complications including massive gastrointestinal bleeding 3

By following this treatment algorithm based on hemorrhoid grade and symptom severity, most patients with internal hemorrhoids can achieve significant symptom relief and improved quality of life.