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

Management of Second-Degree Hemorrhoids

Rubber band ligation is the recommended first-line treatment for symptomatic second-degree hemorrhoids that protrude during proctoscopy but reduce spontaneously after scope removal. 1

Classification and Diagnosis

• The clinical presentation described (protruded swelling from the anus with intact mucosa, no bleeding, no pain, no fistula or fissure, that reduces spontaneously after removal of the scope) is consistent with second-degree internal hemorrhoids according to the American Gastroenterological Association classification 1
• Second-degree hemorrhoids are defined as hemorrhoids that prolapse but reduce spontaneously
• Anoscopy/proctoscopy is essential for proper visualization and confirmation of internal hemorrhoids

Treatment Algorithm

First-line Management:

1. Conservative management should be attempted first for all second-degree hemorrhoids:

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

2. For symptomatic second-degree hemorrhoids that fail conservative management:

   • Rubber band ligation (RBL) is the preferred office-based procedure 1
   • Success rate: 80% improvement and 69% symptom-free at 5-year follow-up

Alternative Options:

• Sclerotherapy is an alternative with 89.9% improvement or cure rate in first/second-degree hemorrhoids 1
• Hemorrhoidectomy is generally reserved for:
  • Failed office-based procedures
  • Third or fourth-degree hemorrhoids
  • Complicated cases

Evidence Supporting Rubber Band Ligation

RBL offers several advantages for second-degree hemorrhoids:

• Outpatient procedure requiring minimal or no anesthesia 2
• Cost-effective compared to surgical options 2
• Shorter recovery time with earlier return to work 3
• High success rate (82.2% of patients symptom-free or improved at 1-3 years follow-up) 4

Multiple studies confirm RBL's effectiveness:

• RBL is equally effective as hemorrhoidectomy for second-degree hemorrhoids 2
• RBL effectively treats bleeding (the most common symptom) in most patients 5, 4
• RBL is more effective than sclerosant injection for relieving anal pain and preventing new prolapse 6

Potential Complications and Post-Procedure Care

Patients should be informed about:

• Common minor complications:
  • Temporary anal discomfort (controllable with NSAIDs) 4
  • Self-limited rectal bleeding in some cases 5
  • Temporary feeling of foreign body in anal canal 5
• Rare severe complications:
  • Significant bleeding requiring intervention
  • Urinary retention
  • Pain requiring narcotic analgesics

Important Considerations and Pitfalls

• Patient selection is crucial: Ensure proper classification of hemorrhoid grade through thorough examination
• Contraindications: Patients with bleeding disorders, immunocompromised status, or pregnancy require special consideration
• Follow-up: Patients should be evaluated 7-10 days after the procedure to assess response and need for additional bands
• Multiple sessions: Some patients may require more than one banding session for complete resolution, especially with multiple hemorrhoids 5
• Failure of RBL: Consider hemorrhoidectomy if symptoms persist after adequate banding attempts

In conclusion, for the described case of second-degree hemorrhoids with spontaneous reduction after proctoscopy, rubber band ligation represents the optimal management strategy after failure of conservative measures, offering an excellent balance of efficacy, safety, and patient convenience.