What are the treatment options for internal hemorrhoids?

Treatment Options for Internal Hemorrhoids

For internal hemorrhoids, treatment should follow a stepwise approach starting with conservative management, progressing to office-based procedures for persistent symptoms, and reserving surgical interventions for advanced or refractory cases. 1

Classification of Internal Hemorrhoids

Internal hemorrhoids are classified into four degrees, which guides treatment selection:

• First degree: Bleed but do not protrude
• Second degree: Protrude with defecation but reduce spontaneously
• Third degree: Protrude and require manual reduction
• Fourth degree: Permanently prolapsed and cannot be reduced 1

First-Line Conservative Management

For all grades of internal hemorrhoids, initial treatment should include:

1. Dietary modifications:

   • Increased fiber intake (25-30g daily)
   • Adequate hydration
   • Avoid straining during defecation 1, 2

2. Lifestyle modifications:

   • Sitz baths 2-3 times daily
   • Avoid prolonged sitting
   • Regular physical activity to promote bowel regularity 1

3. Medications:

   • Stool softeners and osmotic laxatives (polyethylene glycol 17g with 8oz water twice daily)
   • Topical treatments (ointments or suppositories) for short-term symptom relief
   • Phlebotonics (flavonoids) can reduce bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months 1, 2

Caution: Conservative management should be continued even when proceeding to more invasive treatments to prevent recurrence.

Office-Based Procedures (For Grade I-III)

If symptoms persist despite conservative management:

1. Rubber band ligation (first-line procedural treatment):

   • Most effective office-based procedure
   • Resolves symptoms in 89% of patients
   • Up to 20% may require repeated procedures
   • Bands should be applied to the mucosa at the anorectal junction, not directly to hemorrhoidal tissue 1, 2, 3

2. Alternative procedures:

   • Sclerotherapy: 70-85% short-term efficacy but only one-third achieve long-term remission
   • Infrared coagulation: 70-80% success in reducing bleeding and prolapse 1, 2

Note: The American Society of Colon and Rectal Surgeons recommends rubber band ligation over other office-based procedures due to its higher success rate 1, 4.

Surgical Interventions (For Grade III-IV or Refractory Cases)

When office-based procedures fail or for advanced hemorrhoids:

1. Excisional hemorrhoidectomy:

   • Gold standard for grade IV hemorrhoids
   • Low recurrence rate (2-10%)
   • Longer recovery period (9-14 days)
   • Ferguson (closed) technique appears superior to Milligan-Morgan (open) technique regarding postoperative pain and wound healing 1, 5, 2

2. Alternative surgical approaches:

   • Stapled hemorrhoidopexy (Longo procedure):

     • Particularly suitable for circular hemorrhoids
     • Less postoperative pain, shorter operation time and hospital stay
     • Higher recurrence rate compared to excisional hemorrhoidectomy 5

   • Hemorrhoidal Artery Ligation (HAL) with or without Recto-Anal Repair (RAR):

     • Better tolerated but higher recurrence rate
     • Useful for grade II-III hemorrhoids 1, 5

Post-Treatment Care

After procedural or surgical treatment:

• Pain management with NSAIDs
• Continued fiber supplements
• Sitz baths 2-3 times daily
• Stool softeners to prevent constipation
• Monitor for complications: bleeding (0.03-6%), urinary retention (2-36%), infection (0.5-5.5%), and anal stenosis (0-6%) 1

Special Considerations

• Immunocompromised patients: Higher infection risk with any procedure
• Pregnant women: Conservative management preferred; surgery only if absolutely necessary
• Inflammatory bowel disease: Extreme caution with surgical interventions due to high rate of postoperative complications 1

Important: Anal pain is generally not associated with uncomplicated hemorrhoids and suggests other pathology such as thrombosis, fissure, or abscess. A careful anorectal examination with anoscopy is essential for accurate diagnosis 1.