Treatment Options for Recurrent Hemorrhoids: Is Surgery Always Necessary?
Surgery is not always necessary for recurrent hemorrhoids, as treatment should be based on the severity (grade) of hemorrhoids, with non-operative techniques preferred when feasible due to less pain and complications compared to surgical options. 1
Grading System and Treatment Algorithm
Hemorrhoid treatment should follow a stepwise approach based on their classification:
First-degree hemorrhoids (bleed but do not protrude): Medical therapy is most appropriate, focusing on adequate fiber and water intake 1
Second-degree hemorrhoids (protrude with defecation but reduce spontaneously): Non-operative techniques are recommended 1
Third-degree hemorrhoids (protrude and require manual reduction): Non-operative techniques may be attempted first, but surgical options are more effective 1
Fourth-degree hemorrhoids (cannot be reduced): Surgical hemorrhoidectomy is typically required 1
Non-Operative Treatment Options
For recurrent hemorrhoids that are first, second, or even some third-degree cases, several non-surgical options exist:
Rubber band ligation: Most effective non-operative technique with the lowest recurrence rate, though associated with more discomfort than other non-surgical methods 1
Injection sclerotherapy: Useful for first and second-degree hemorrhoids but has a relatively high relapse rate 1
Infrared photocoagulation: Effective for controlling hemorrhoidal bleeding in 67-96% of patients with first or second-degree hemorrhoids 1
Diathermy/bipolar coagulation: Alternative non-operative options with fewer complications 1
When Surgery Is Necessary
Surgical hemorrhoidectomy should be reserved for specific situations:
- Failure of medical and non-operative therapy 1
- Symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids 1
- Hemorrhoids with concomitant anorectal conditions requiring surgery 1
- Patient preference after discussion of treatment options 1
Only about 5-10% of patients, usually those with third or fourth-degree hemorrhoids, require surgical hemorrhoidectomy 1.
Surgical Options and Considerations
When surgery is necessary, several options exist:
Conventional hemorrhoidectomy (open or closed): Most effective treatment with uncommon recurrence when properly performed, but associated with more pain and complications 1
Stapled hemorrhoidopexy: Associated with less postoperative pain than conventional methods, but has shown higher recurrence rates in recent literature 2, 3
Transanal hemorrhoidal dearterialization: May be as effective as stapled hemorrhoidopexy with comparable complications and recurrence rates 2
Important Considerations and Pitfalls
Avoid anal dilatation: Despite some European acceptance, this technique carries significant risk of sphincter injury and incontinence (52% of patients had impaired continence at 17-year follow-up) 1
Thrombosed hemorrhoids: The decision between non-operative management and surgical excision should be based on physician expertise and patient preference 1
Avoid incision and drainage of thrombosed hemorrhoids due to persistent bleeding and higher recurrence rates 1
Laser hemorrhoidectomy offers no advantage over conventional techniques and is more costly 1
Recovery time: Patients typically require 2-4 weeks to return to work following surgical hemorrhoidectomy, with narcotic analgesics generally required for pain management 1
Recurrence rates: Surgical hemorrhoidectomy has the lowest recurrence rates (2-10%) compared to non-operative techniques 4, 3
For recurrent hemorrhoids, the treatment approach should be guided by the grade of hemorrhoids, predominant symptoms, and previous treatment responses rather than automatically resorting to surgery 4, 5.