What are the treatment options for internal hemorrhoids?

Management of Internal Hemorrhoids

The most effective treatment approach for internal hemorrhoids begins with conservative management including increased fiber and water intake, followed by office-based procedures like rubber band ligation for grades I-III, and surgical interventions for grade IV or refractory cases. 1

Classification and Clinical Presentation

• Internal hemorrhoids are classified into four grades based on their level of prolapse:

  • Grade I: Bleed but do not prolapse 1, 2
  • Grade II: Prolapse but reduce spontaneously 1, 2
  • Grade III: Prolapse and require manual reduction 1, 2
  • Grade IV: Prolapse and cannot be reduced 1, 2

• The primary symptom of internal hemorrhoids is painless bright red bleeding during defecation 2

• Other symptoms may include prolapse, mucus discharge, and secondary anal itching 2

• Pain is generally not associated with uncomplicated internal hemorrhoids and suggests other pathologies or complications like thrombosis 2

First-Line Treatment: Conservative Management

• Conservative management is recommended as first-line treatment for all grades of hemorrhoids 1
• Key components include:
  • Increased dietary fiber and water intake to soften stool and reduce straining 1
  • Bulk-forming agents like psyllium husk (5-6 teaspoons with 600 mL water daily) 1
  • Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1
  • Avoiding prolonged straining during defecation 1, 3

Pharmacological Treatment Options

• Flavonoids are recommended to improve venous tone and control acute bleeding in all grades of hemorrhoids 3

• Topical treatments for symptom relief include:

  • Analgesics (e.g., lidocaine) for pain and itching 1, 3
  • Corticosteroid creams for perianal inflammation (limited to 7 days to prevent skin thinning) 1, 3
  • Topical muscle relaxants for pain associated with sphincter hypertonicity 3

• Suppositories may provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

• Long-term use of high-potency corticosteroid suppositories should be avoided due to potential harm 1

Office-Based Procedures

• Rubber band ligation is the most effective office-based procedure for grades I-III hemorrhoids 1

  • Success rates range from 70.5% to 89% 1, 4
  • The procedure works by causing tissue necrosis and subsequent scarring that fixes connective tissue to the rectal wall 1
  • Bands must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
  • Up to 3 hemorrhoids can be banded in a single session 1
  • Complications include pain (5-60% of patients), bleeding, abscess, and rarely necrotizing pelvic sepsis 1
  • Contraindicated in immunocompromised patients 1

• Injection sclerotherapy is suitable for grades I and II hemorrhoids 1

  • Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
  • Efficacious in the short term (70-85% of patients) but long-term remission occurs in only one-third of patients 5

• Infrared coagulation uses heat to coagulate hemorrhoidal tissue 5

  • Achieves 70-80% success in reducing bleeding and prolapse 5

Surgical Management

• Surgical intervention is indicated for:

  • Failure of medical and non-operative therapy 1
  • Symptomatic grade III or IV hemorrhoids 1
  • Mixed internal and external hemorrhoids 1

• Surgical options include:

  • Conventional excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson techniques) 1

    • Most effective treatment overall, particularly for grade III hemorrhoids 1
    • Low recurrence rate of 2-10% 1, 5
    • Longer recovery period (9-14 days) 5

  • Stapled hemorrhoidopexy 1

  • Hemorrhoidal artery ligation 1

• Not recommended surgical approaches:

  • Anal dilatation (associated with high rates of incontinence) 1
  • Cryotherapy (causes prolonged pain, foul-smelling discharge) 1

Special Considerations

• Pregnancy: Hemorrhoids occur in approximately 80% of pregnant persons, especially in the third trimester 1

  • Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents, and osmotic laxatives 1
  • Hydrocortisone foam can be used safely in the third trimester 1

• Important diagnostic considerations:

  • Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
  • Up to 20% of patients with hemorrhoids have concomitant anal fissures 2
  • Always consider other causes for anorectal symptoms, as hemorrhoids may not be the primary cause 1, 2

• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1

Treatment Algorithm Based on Hemorrhoid Grade

• Grade I: Conservative management → Pharmacological treatment → Sclerotherapy or rubber band ligation if symptoms persist 1, 3
• Grade II: Conservative management → Pharmacological treatment → Rubber band ligation if symptoms persist 1, 3
• Grade III: Conservative management → Rubber band ligation → Surgical hemorrhoidectomy if unsuccessful 1, 5
• Grade IV: Conservative management → Surgical hemorrhoidectomy 1, 5