What are the treatment options for internal hemorrhoids?

Treatment Options for Internal Hemorrhoids

For internal hemorrhoids, a stepwise approach beginning with conservative management is recommended, with rubber band ligation being the most effective office-based procedure for first to third-degree hemorrhoids that fail to respond to conservative measures. 1

Classification of Hemorrhoids

• Internal hemorrhoids are classified into four grades based on symptoms and physical findings:
  • Grade I: Bleeding without protrusion
  • Grade II: Protrusion with spontaneous reduction
  • Grade III: Protrusion requiring manual reduction
  • Grade IV: Irreducible protrusion 1, 2

First-Line Treatment: Conservative Management

• Conservative management is recommended as the initial approach for all grades of hemorrhoids 1
• Key components include:
  • Increased dietary fiber (5-6 teaspoons of psyllium husk with 600mL water daily) and water intake to soften stool and reduce straining 1, 2
  • Avoidance of prolonged toilet sitting and straining during defecation 1, 3
  • Topical treatments for symptom relief (analgesics for pain and itching, corticosteroids for perianal skin irritation for no more than 7 days) 1
  • Sitz baths (warm water soaks) to reduce inflammation and discomfort 1
  • Flavonoids (phlebotonics) can help relieve symptoms, though recurrence rates reach 80% within 3-6 months after treatment cessation 1, 2

Office-Based Procedures for Persistent Symptoms

When conservative measures fail, the following office-based procedures are recommended based on hemorrhoid grade:

Rubber Band Ligation

• Most effective office-based procedure for first to third-degree hemorrhoids with success rates of 70.5-89% 1, 2
• Technique: Band is placed at least 2cm proximal to dentate line to avoid severe pain 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners limit treatment to 1-2 columns at a time 1
• Complications include pain (5-60% of patients), abscess, urinary retention, band slippage, and occasional severe bleeding when the eschar sloughs (1-2 weeks post-treatment) 4, 1
• Contraindicated in immunocompromised patients due to risk of necrotizing pelvic infection 4, 1

Sclerotherapy

• Suitable for first and second-degree hemorrhoids 1
• Uses sclerosing agents to cause fibrosis and tissue shrinkage 1
• Short-term efficacy in 70-85% of patients, but long-term remission in only one-third 2
• Less effective than rubber band ligation according to meta-analyses 4, 1

Infrared Photocoagulation

• Effective for first and second-degree hemorrhoids 4
• Success rates for controlling bleeding range from 67-96% 4
• Complications including pain and bleeding are uncommon 4
• Requires fewer treatments than sclerotherapy but more than rubber band ligation 4

Bipolar Diathermy

• Success rates for bleeding control of 88-100% in randomized trials 4, 1
• Does not eliminate prolapsing tissue, and up to 20% of patients will require excisional hemorrhoidectomy 4
• Complications include pain, bleeding, fissure, or sphincter spasm in about 12% of patients 4

Surgical Management

• Indicated for:
  • Failure of medical and non-operative therapy
  • Symptomatic third or fourth-degree hemorrhoids
  • Mixed internal and external hemorrhoids 1

Conventional Excisional Hemorrhoidectomy

• Most effective treatment overall, particularly for third-degree hemorrhoids 4, 1
• Low recurrence rate (2-10%) 1, 2
• Associated with more pain and complications than non-operative techniques 4
• Recovery period of 9-14 days 2

Stapled Hemorrhoidopexy

• Treatment option for circular hemorrhoids and grade III-IV hemorrhoids 1, 5
• Advantages: reduced postoperative pain, shorter operation time and hospital stay, faster recovery 5
• Disadvantage: higher recurrence rate compared to conventional hemorrhoidectomy 5

Important Considerations and Pitfalls

• Not all anorectal symptoms are due to hemorrhoids; conditions like anal fissures, abscesses, or fistulas may coexist or be the primary cause 1
• 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
• Anal dilatation is not recommended due to high rates of associated incontinence (52% at 17-year follow-up) 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• If symptoms worsen or fail to improve within 1-2 weeks of treatment, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1