When is surgery indicated for internal hemorrhoids?

Indications for Internal Hemorrhoids Surgery

Surgery is indicated for internal hemorrhoids when there is failure of medical and non-operative therapy, symptomatic third or fourth-degree hemorrhoids, or mixed internal and external hemorrhoids. 1

Classification of Internal 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

Treatment Algorithm

First-Line Treatment

• Conservative management is the first-line treatment for all hemorrhoid grades 1:
  • Increased dietary fiber and water intake to soften stool and reduce straining 1
  • Topical treatments for symptomatic relief (analgesics, corticosteroids for short-term use ≤7 days) 1
  • Sitz baths to reduce inflammation and discomfort 1

Second-Line Treatment (Office-Based Procedures)

• For Grade I-III hemorrhoids that fail conservative management:
  • Rubber band ligation is the most effective office-based procedure with success rates of 70.5-89% 1
  • Injection sclerotherapy is suitable for first and second-degree hemorrhoids 1
  • Bipolar diathermy has success rates of 88-100% for bleeding control in Grade II hemorrhoids 1

Surgical Indications

Surgery is specifically indicated in the following scenarios:

• Failure of conservative management and office-based procedures 1
• Symptomatic Grade III or IV internal hemorrhoids 1, 2
• Mixed internal and external hemorrhoids 1
• Recurrent hemorrhoidal disease despite less invasive treatments 2
• Complicated hemorrhoids (e.g., strangulated) 2

Surgical Options

• Conventional excisional hemorrhoidectomy (open Milligan-Morgan or closed Ferguson techniques) is the most effective treatment overall, particularly for third-degree hemorrhoids, with a recurrence rate of only 2-10% 1, 2
• Stapled hemorrhoidopexy has advantages of reduced postoperative pain, shorter operation time, hospital stay, and faster recovery, but has a higher recurrence rate compared to conventional hemorrhoidectomy 2
• Hemorrhoidal artery ligation, sometimes combined with recto-anal repair (HAL/RAR), offers better tolerance but higher recurrence rates 2

Important Considerations and Contraindications

• 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
• Immunocompromised patients (including those with uncontrolled AIDS, neutropenia, and severe diabetes mellitus) have increased risk of necrotizing pelvic infection with certain procedures like rubber band ligation 1
• Always rule out other causes of rectal bleeding before attributing symptoms to hemorrhoids 1, 2
• Colonoscopy should be considered if there is concern for inflammatory bowel disease or cancer based on patient history or physical examination 2

Complications of Surgical Treatment

• Common complications after hemorrhoidectomy include urinary retention, bleeding, anal stenosis, infection, and incontinence, with rates ranging from 0.03-36% 2
• Sphincter defects have been documented in up to 12% of patients after hemorrhoidectomy 2
• Stapled procedures carry rare but serious risks including rectal perforation and pelvic sepsis 2

Special Populations

• For pregnant patients with hemorrhoids, safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
• Osmotic laxatives such as polyethylene glycol or lactulose can be used safely during pregnancy 1
• Hydrocortisone foam can be used safely for hemorrhoids in the third trimester 1