What treatments are available for internal hemorrhoids?

Treatment Options for Internal Hemorrhoids

For internal hemorrhoids, first-line treatment includes conservative measures such as increased fiber intake (25-30g daily), adequate hydration, sitz baths 2-3 times daily, and mesalamine suppositories, which have shown superior efficacy compared to placebo. 1

Conservative Management (First-Line)

Conservative management should be the initial approach for all grades of internal hemorrhoids:

• Dietary modifications:

  • Increase fiber intake to 25-30g daily
  • Ensure adequate hydration
  • Consider bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600mL water daily) 1, 2

• Behavioral modifications:

  • Avoid straining during defecation
  • Avoid prolonged sitting
  • Regular physical activity to promote bowel regularity
  • Follow the "TONE" approach: Three minutes at defecation, Once-a-day defecation frequency, No straining, Enough fiber 2

• Topical treatments:

  • Sitz baths 2-3 times daily
  • Topical hydrocortisone preparations for inflammation and itching relief 1
  • Topical 4% or 5% lidocaine patches (more effective than creams or ointments) 1

Medical Treatment (When Conservative Measures Are Insufficient)

• Mesalamine (5-ASA) suppositories - most effective option with superior efficacy compared to placebo (RR 0.44,95% CI 0.34-0.56) 1
• Hydrocortisone suppositories - effective for short-term management but avoid long-term use due to safety concerns 1
• Phlebotonics (e.g., flavonoids) - reduce bleeding, rectal pain, and swelling, though symptoms may recur within 3-6 months after stopping treatment 3

Procedural Treatment (For Persistent Symptoms)

For grades I-III internal hemorrhoids that don't respond to conservative and medical therapy:

1. Rubber band ligation - first-line procedural treatment

   • Resolves symptoms in 89% of patients
   • Up to 20% may require repeated procedures
   • Most effective office-based procedure 1, 3

2. Sclerotherapy

   • Short-term efficacy of 70-85%
   • Long-term remission in only one-third of patients 1, 3

3. Infrared coagulation

   • 70-80% success in reducing bleeding and prolapse
   • Alternative for grades I-II 1, 3

4. Hemorrhoidal artery ligation

   • Useful for grade II-III hemorrhoids
   • Less pain and quicker recovery 1

Surgical Options (For Advanced Cases)

For grade III-IV hemorrhoids that fail less invasive treatments:

• Excisional hemorrhoidectomy - gold standard for grade IV hemorrhoids

  • Low recurrence rate (2-10%)
  • Longer recovery period (9-14 days) 1, 3

• Stapled hemorrhoidopexy - elevates grade III or IV hemorrhoids to normal position

  • Potential for postoperative complications 4

Special Considerations

• Pregnancy: Conservative management is preferred; topical hydrocortisone preparations are safe and effective 1
• Immunocompromised patients: Higher infection risk with procedures; careful evaluation needed 1
• Liver cirrhosis/portal hypertension: Caution needed to distinguish anal varices from hemorrhoids 1
• Inflammatory bowel disease: Extreme caution with surgical interventions due to high complication rates 1

Post-Treatment Care

• Pain management with NSAIDs
• Continue fiber supplements
• Sitz baths 2-3 times daily
• Stool softeners to prevent constipation
• Monitor for complications (bleeding, urinary retention, infection) 1

Common Pitfalls to Avoid

1. Misdiagnosis: Anorectal symptoms are often misattributed to hemorrhoids when other conditions may be present. A thorough diagnostic approach including anoscopy is necessary 1

2. Inadequate fiber supplementation: Many patients don't take enough fiber to make a difference. Ensure adequate dosing (25-30g daily) 1, 2

3. Premature escalation to procedures: Conservative management should be given adequate time to work before moving to more invasive options 1, 2

4. Delayed treatment of thrombosed hemorrhoids: Outpatient clot evacuation within 72 hours of onset can decrease pain and reduce risk of repeat thrombosis 3