What is the treatment for grade 4 internal hemorrhoids?

Treatment of Grade 4 Internal Hemorrhoids

Grade 4 internal hemorrhoids require surgical hemorrhoidectomy as the definitive treatment, with excisional hemorrhoidectomy (Milligan-Morgan or Ferguson techniques) being the gold standard, achieving recurrence rates of only 2-10%. 1, 2, 3

Why Surgery is Indicated for Grade 4 Hemorrhoids

Grade 4 hemorrhoids are irreducibly prolapsed, meaning they cannot be manually reduced back into the anal canal. 1, 2 This severity exceeds the threshold for conservative management or office-based procedures like rubber band ligation, which are only appropriate for grades 1-3. 1, 3

Surgical hemorrhoidectomy is specifically indicated for:

• Symptomatic grade 3 or 4 hemorrhoids 1
• Failure of medical and non-operative therapy 1
• Mixed internal and external hemorrhoids 1
• Concomitant conditions requiring surgery (fissures, fistulas) 1

Surgical Options

Conventional Excisional Hemorrhoidectomy (First-Line)

This is the most effective treatment overall for grade 4 hemorrhoids, with the lowest recurrence rate of 2-10%. 1, 2, 3

Two equivalent techniques exist:

• Open technique (Milligan-Morgan): Wounds left open to heal by secondary intention 1
• Closed technique (Ferguson): Primary wound closure, which may offer superior postoperative pain control and faster healing 4

Key advantages:

• Highest long-term success rate (90-98%) 1
• Lowest recurrence (2-10%) 1, 2
• Definitive treatment for severe disease 1

Important drawbacks:

• Significant postoperative pain requiring narcotic analgesics 1
• Recovery time of 2-4 weeks before return to work 1
• Approximately 10% complication rate (bleeding, fissure, abscess, stenosis, urinary retention) 5

Stapled Hemorrhoidopexy (Alternative Option)

This procedure may be considered for grade 4 hemorrhoids, particularly with circular prolapse. 4

Advantages over excisional hemorrhoidectomy:

• Faster postoperative recovery 3, 4
• Less postoperative pain 3, 4
• Shorter hospital stay 4

Critical disadvantage:

• Higher recurrence rate compared to excisional hemorrhoidectomy 3, 4

Procedures to AVOID

Anal dilatation should never be used due to a 52% incontinence rate at 17-year follow-up. 1

Cryotherapy is not recommended due to prolonged pain, foul-smelling discharge, and need for additional therapy. 1

Rubber band ligation is inappropriate for grade 4 hemorrhoids as they are irreducible and exceed the anatomic limits for this procedure. 1, 3

Preoperative Considerations

Before proceeding with surgery:

• Check hemoglobin/hematocrit to assess for anemia from chronic bleeding 6
• Perform colonoscopy if the patient is over 50 years or has risk factors for colorectal cancer, as hemorrhoids alone do not cause positive fecal occult blood tests 1, 6
• Optimize any anemia with transfusion if hemodynamically indicated 1

Postoperative Pain Management

Pain control is critical given the significant discomfort from excisional hemorrhoidectomy:

• NSAIDs and narcotic analgesics 3
• Fiber supplements to prevent constipation 3
• Topical antispasmodics 3
• Regular sitz baths (warm water soaks) 1

Common Pitfalls to Avoid

Never assume all anorectal symptoms are from hemorrhoids alone. Up to 20% of patients have concomitant anal fissures, and other pathology (abscesses, fistulas, inflammatory bowel disease, cancer) must be excluded. 1, 7

Do not delay definitive surgical treatment in grade 4 hemorrhoids, as conservative measures and office procedures will fail. 1, 3

Avoid simple incision and drainage if external thrombosis is present, as this leads to persistent bleeding and higher recurrence. 1