What are the treatment options for different hemorrhoid gradings?

Treatment Options for Different Hemorrhoid Gradings

Rubber band ligation is the recommended initial procedure of choice for first-, second-, and third-degree hemorrhoids due to its higher efficacy rate, while surgical hemorrhoidectomy is the most effective treatment for third- and fourth-degree hemorrhoids. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades based on symptoms and physical findings 1:

  • Grade I: Bleeding without prolapse
  • Grade II: Prolapse with spontaneous reduction
  • Grade III: Prolapse requiring manual reduction
  • Grade IV: Irreducible prolapse

• External hemorrhoids typically cause symptoms only when thrombosed, resulting in acute pain 1

Treatment Algorithm by Hemorrhoid Grade

Conservative Management (All Grades)

• First-line treatment for all hemorrhoid grades involves dietary and lifestyle modifications 1
• Increased fiber (5-6 teaspoons of psyllium husk with 600 mL water daily) and water intake to soften stool and reduce straining 1
• Avoidance of straining during defecation 2
• Sitz baths for symptomatic relief 2
• Topical treatments for symptom relief (analgesics, corticosteroids for short-term use ≤7 days) 1, 2

Grade I Internal Hemorrhoids

• Conservative management as first-line approach 1
• If persistent symptoms:
  • Rubber band ligation (success rates up to 89%) 1
  • Injection sclerotherapy (70-85% short-term success) 3
  • Infrared photocoagulation (70-80% success in reducing bleeding and prolapse) 3

Grade II Internal Hemorrhoids

• Conservative management as first-line approach 1
• For persistent symptoms:
  • Rubber band ligation is the preferred office-based procedure 1, 4
  • Sclerotherapy as an alternative option 1
  • Infrared photocoagulation as another alternative 3
  • Bipolar diathermy (success rates for bleeding control: 88-100%) 5

Grade III Internal Hemorrhoids

• Initial trial of conservative management 1
• Rubber band ligation is effective for many cases 1
• Surgical hemorrhoidectomy is the most effective treatment overall for third-degree hemorrhoids 5
• Hemorrhoidal artery ligation may be considered as it causes less pain and allows faster recovery 4

Grade IV Internal Hemorrhoids

• Surgical hemorrhoidectomy is the treatment of choice 1, 3
• Options include:
  • Conventional excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson techniques) 5
  • Stapled hemorrhoidopexy for circular hemorrhoids 6
  • Recurrence rate following properly performed hemorrhoidectomy is uncommon (2-10%) 3

Management of Thrombosed External Hemorrhoids

Early Presentation (within 72 hours)

• Surgical excision under local anesthesia is recommended for faster pain relief and reduced recurrence risk 2
• Simple incision and drainage is not recommended due to persistent bleeding and higher recurrence rates 2

Later Presentation (>72 hours)

• Conservative management is preferred as natural resolution has begun 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks (92% resolution rate) 2
• Stool softeners, oral and topical analgesics 3

Specific Surgical Techniques

Conventional Hemorrhoidectomy

• Can be performed with either open or closed techniques 5
• Milligan-Morgan technique (open): internal and external components are excised and skin is left open 5
• Ferguson technique (closed): hemorrhoid components are excised and wounds closed primarily 5
• Postoperative pain is the major drawback, requiring narcotic analgesics 5
• Most patients do not return to work for 2-4 weeks following surgery 5

Stapled Hemorrhoidopexy

• Elevates grade III or IV hemorrhoids to their normal anatomic position 4
• Associated with reduced postoperative pain, shorter operation time and hospital stay 6
• Disadvantage of higher recurrence rate compared to conventional hemorrhoidectomy 6

Important Considerations and Pitfalls

• Avoid anal dilatation as a treatment option due to high rates of associated incontinence (52% at 17-year follow-up) 5
• Necrotizing pelvic sepsis is a rare but serious complication of rubber band ligation, with increased risk in immunocompromised patients 1
• Avoid long-term use of high-potency corticosteroid creams (>7 days) as they can cause thinning of perianal and anal mucosa 2
• Cryotherapy is rarely used now due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 5
• If symptoms worsen or fail to improve within 1-2 weeks, reassessment is recommended 2
• Hemorrhoids alone do not cause positive stool guaiac tests, so fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1