What is the recommended management for a patient with a second-degree hemorrhoid (haemorrhoid) presenting with a protruded swelling from the anus during proctoscopy (proctoscopic examination) that reduces spontaneously after removal of the scope, with intact mucosa and no bleeding, pain, fistula, or fissure?

Management of Second-Degree Hemorrhoids

Rubber band ligation is the recommended first-line treatment for second-degree hemorrhoids that have failed conservative management, as it has a success rate of 80% improvement and 69% symptom-free at 5-year follow-up. 1

Diagnosis and Classification

The clinical presentation described in the question is consistent with second-degree internal hemorrhoids, which are defined as hemorrhoids that prolapse during straining but reduce spontaneously. The key diagnostic features include:

• Protruded swelling from the anus during examination
• Spontaneous reduction after removal of scope
• Intact mucosa
• Absence of bleeding, pain, fistula, or fissure

Treatment Algorithm

1. Initial Management: Conservative Approach

   • High-fiber diet (25-30g daily)
   • Increased water intake (8-10 glasses daily)
   • Lifestyle modifications (regular physical activity, avoiding prolonged sitting)
   • Phlebotonics (flavonoids) for symptom management 1

2. If conservative management fails, proceed to office-based procedures:

   • Rubber band ligation (RBL) - first-line procedural treatment 1
   • Sclerotherapy - alternative option with 89.9% improvement or cure rate 1

3. Surgical options (for refractory cases or higher-grade hemorrhoids):

   • Hemorrhoidectomy
   • Minimally invasive alternatives (Ligasure hemorrhoidectomy, Doppler-guided hemorrhoidal artery ligation) 1

Evidence Supporting Rubber Band Ligation

RBL is particularly effective for second-degree hemorrhoids:

• Success rate of 80% improvement and 69% symptom-free at 5-year follow-up 1
• Recent research shows 86.8% of patients become asymptomatic after treatment, with 84.5% remaining asymptomatic 2 years later 2
• A study of 50 patients with grade II and III hemorrhoids showed significant symptom improvement after RBL, with only 13 patients occasionally symptomatic after 6 months 3

Procedure Details and Complications

• RBL involves applying rubber bands to the mucosa at the anorectal junction, not directly to hemorrhoidal tissue 4
• Complications are generally minor and manageable:
  • Pain (16.16% in one large study) 2
  • Self-limited rectal bleeding (24% within 10 days in one study) 3
  • Serious complications are rare (2.5% hospitalization rate) 5
  • Risk factors for pain include multiple banding, young age, male sex, and external hemorrhoids 2

Important Considerations and Pitfalls

• Do not perform RBL on thrombosed, gangrenous, or fourth-degree hemorrhoids as this may lead to severe pain and complications
• Avoid RBL in patients on anticoagulants without proper medication adjustment
• Use caution in patients with inflammatory bowel disease due to higher risk of complications 1
• Ensure proper band placement at the anorectal junction, not on hemorrhoidal tissue directly, to minimize pain 4
• Consider multiple sessions for patients with multiple hemorrhoids rather than treating all at once 2

Follow-up Care

• Patients should be informed about potential minor complications (pain, bleeding)
• Recommend sitz baths and mild analgesics for post-procedure discomfort
• Schedule follow-up evaluation to assess treatment response
• Consider repeat RBL for recurrent symptoms (15.49% recurrence rate in one study) 2