What are the latest treatment options for grade 3 and 4 hemorrhoids?

Treatment of Grade 3 and 4 Hemorrhoids

For grade 3 hemorrhoids, rubber band ligation should be the first procedural intervention after conservative management fails, while grade 4 hemorrhoids require surgical hemorrhoidectomy as definitive treatment. 1, 2

Initial Conservative Management (All Grades)

Before any procedural intervention, all patients with grade 3 and 4 hemorrhoids should receive:

• Increased dietary fiber (5-6 teaspoonfuls of psyllium husk with 600 mL water daily) to soften stool and reduce straining 1
• Adequate water intake to maintain soft, bulky stools 1
• Flavonoids for symptom relief and bleeding control, which improve venous tone and are effective for all grades of hemorrhoids 3, 2
• Avoidance of straining during defecation to prevent symptom exacerbation 1

Treatment Algorithm for Grade 3 Hemorrhoids

First-Line Procedural Treatment: Rubber Band Ligation

Rubber band ligation is the most effective office-based procedure for grade 3 hemorrhoids, with success rates of 70.5% to 89% depending on follow-up duration. 1, 2

• The procedure works by placing a band at least 2 cm proximal to the dentate line to avoid severe pain, causing tissue necrosis and scarring that fixes tissue to the rectal wall 1
• Can be performed in an office setting without anesthesia 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
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1, 4
• Pain occurs in 5-60% of patients but is typically manageable with sitz baths and over-the-counter analgesics 1, 5
• Repeated banding may be needed in up to 20% of patients 2

When Rubber Band Ligation Fails or Is Inappropriate

Surgical hemorrhoidectomy becomes indicated when:

• Medical and office-based therapy have failed 1
• Mixed internal and external hemorrhoids are present 1
• Concomitant conditions (fissure, fistula) require surgery 1
• Patient presents with anemia from hemorrhoidal bleeding 1

Treatment for Grade 4 Hemorrhoids

Surgical hemorrhoidectomy is the definitive treatment for grade 4 hemorrhoids, as these are irreducible and not amenable to office-based procedures. 2

Surgical Options

Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) remains the gold standard:

• Ferguson (closed) hemorrhoidectomy involves excising hemorrhoid components and closing wounds primarily 6, 7
• Milligan-Morgan (open) hemorrhoidectomy excises hemorrhoids leaving wounds open to heal secondarily over 4-8 weeks 6
• Ferguson technique appears superior with respect to postoperative pain and wound healing 8, 7
• Recurrence rate is only 2-10%, the lowest of all treatment modalities 1, 2, 7
• Success rate approaches 90-98% 1

Stapled hemorrhoidopexy is an alternative option:

• Particularly advisable for circular hemorrhoids 8
• Associated with reduced postoperative pain, shorter operation time and hospital stay, and faster recovery (9-14 days vs longer for excisional) compared to excisional hemorrhoidectomy 8, 2
• Higher recurrence rate than conventional hemorrhoidectomy is the main disadvantage 8, 9
• Can be employed in emergency situations of acute anal prolapse 8

Hemorrhoidal Artery Ligation (HAL/RAR) is another option:

• Demonstrates better tolerance of the procedure 8
• Higher recurrence rate compared to excisional hemorrhoidectomy 8
• Qualifies for treatment of both grade 3 and 4 hemorrhoids 8

Managing Postoperative Pain

The major drawback of surgical hemorrhoidectomy is postoperative pain:

• Narcotic analgesics are generally required 6
• Most patients do not return to work for 2-4 weeks following surgery 6, 1
• Nonsteroidal anti-inflammatory drugs, fiber supplements, and topical antispasmodics can be used 9
• Sitz baths provide symptomatic relief 1
• No significant difference in pain between diathermy and scissors techniques, though oral pain medication requirement may be less with diathermy 6

Critical Pitfalls to Avoid

• Never perform anal dilatation - this technique has a 52% incontinence rate at 17-year follow-up and causes sphincter injuries 6, 1
• Avoid cryotherapy - rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 6, 1
• Do not attribute anemia to hemorrhoids without proper evaluation - colonoscopy should be performed to rule out proximal colonic pathology 1
• Avoid simple incision and drainage of thrombosed components - this leads to persistent bleeding and higher recurrence 1
• Do not delay definitive treatment when active bleeding has caused anemia, as continued blood loss will occur 1

Special Considerations

For thrombosed external hemorrhoids complicating grade 3-4 disease:

• If presenting within 72 hours: excision under local anesthesia provides faster pain relief and reduced recurrence risk 1, 2
• If presenting after 72 hours: conservative management with stool softeners, oral and topical analgesics (5% lidocaine) 1, 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks shows 92% resolution rate 1, 3