What are the treatment approaches for different degrees of hemorrhoids?

Treatment Approaches for Different Degrees of Hemorrhoids

All hemorrhoids should initially receive conservative management with increased fiber (5-6 teaspoonfuls psyllium with 600 mL water daily) and adequate water intake, but the procedural and surgical interventions escalate systematically based on hemorrhoid grade and response to treatment. 1

Classification System

Internal hemorrhoids are graded into four categories based on prolapse severity: 1

• Grade I: Bleeding without prolapse beyond the anal canal 1
• Grade II: Prolapse beyond the anus with spontaneous reduction 2
• Grade III: Prolapse requiring manual reduction 2
• Grade IV: Irreducible prolapse 2

External hemorrhoids typically cause symptoms only when thrombosed, presenting with acute pain and a palpable perianal lump. 1

Conservative Management (First-Line for All Grades)

Dietary and lifestyle modifications form the foundation of treatment regardless of hemorrhoid grade. 1

• Increase fiber intake to 5-6 teaspoonfuls psyllium with 600 mL water daily to soften stool and reduce straining 1
• Avoid straining during defecation 1
• Take regular sitz baths to reduce inflammation and discomfort 1

Topical treatments provide symptomatic relief: 1

• Topical 0.3% nifedipine with 1.5% lidocaine ointment applied every 12 hours for two weeks achieves 92% resolution rate for thrombosed external hemorrhoids (compared to 45.8% with lidocaine alone) 1
• Short-term topical corticosteroids (≤7 days maximum) reduce local inflammation but must be limited to avoid perianal tissue thinning 1, 3
• Flavonoids (phlebotonics) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2

Grade I Hemorrhoids

Rubber band ligation is the first procedural intervention when conservative management fails, with success rates of 70.5-89%. 1

Alternative office-based procedures include: 1

• Injection sclerotherapy (suitable for Grade I-II, causes fibrosis and tissue shrinkage) 1
• Infrared photocoagulation (67-96% success rates) 1
• Bipolar diathermy (88-100% success for bleeding control) 1

Grade II Hemorrhoids

Rubber band ligation remains the most effective office-based procedure, more effective than sclerotherapy and requiring fewer additional treatments than infrared photocoagulation. 1

The procedure works by encircling redundant mucosa at least 2 cm proximal to the dentate line, causing tissue necrosis and scarring that fixes tissue to the rectal wall. 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

Common complications include: 4

• Pain (5-60% of patients, typically manageable with sitz baths and over-the-counter analgesics) 4
• Band slippage, prolapse/thrombosis of adjacent hemorrhoids (approximately 5%) 1
• Severe bleeding when eschar sloughs (typically 1-2 weeks post-treatment) 1

Critical contraindication: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic sepsis. 1

Grade III Hemorrhoids

Treatment options include rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy. 5

Rubber band ligation has success rates of 70-89% but higher recurrence rates than surgical options. 1 It causes less postoperative pain and fewer complications than hemorrhoidectomy. 5

Surgical hemorrhoidectomy is indicated when: 1

• Medical and office-based therapy have failed after adequate trial (typically 4-8 weeks) 3
• Persistent bleeding causes anemia requiring transfusion consideration 3
• Mixed internal and external hemorrhoids are present 1
• Concomitant conditions (fissure, fistula) require surgery 1

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) achieves the lowest recurrence rate of 2-10%. 1, 2 The Ferguson technique with primary wound closure shows superior outcomes regarding postoperative pain and healing. 3 Major drawback is postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks. 1, 3

Grade IV Hemorrhoids

Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) is the gold standard, with recurrence rates of only 2-10%. 3

Critical timing consideration: Acutely incarcerated or thrombosed Grade IV hemorrhoids require initial medical optimization unless tissue necrosis is present. 3 Severe edema and inflammation make tissue planes difficult to identify, increasing risk of sphincter injury. 3

Initial conservative management before surgery includes: 3

• Increased fiber and water intake (5-6 teaspoonfuls psyllium with 600 mL water daily) 3
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours (92% resolution rate for acute symptoms) 3
• Short-term topical corticosteroids (≤7 days maximum) 3

Rubber band ligation is contraindicated for Grade IV hemorrhoids as it does not address the extensive prolapse and external component. 3

Thrombosed External Hemorrhoids

For presentation within 72 hours: Excision under local anesthesia provides faster pain relief and reduces recurrence risk. 1

For presentation beyond 72 hours: Conservative management is preferred as spontaneous resolution has begun, including: 1, 3

• Stool softeners 1
• Oral and topical analgesics (5% lidocaine) 2
• Topical 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks 1

Never perform simple incision and drainage of the thrombus—this leads to persistent bleeding and higher recurrence rates. 1, 3

Critical Pitfalls to Avoid

Anal dilatation should be completely abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries. 1, 3

Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy. 1, 3

Never use corticosteroid creams for more than 7 days as prolonged use causes perianal and anal mucosa thinning, increasing injury risk. 1, 3

The clinical triad of severe pain, high fever, and urinary retention after any hemorrhoid treatment suggests necrotizing pelvic sepsis, requiring emergency examination under anesthesia with radical debridement. 3, 4

Never attribute anemia to hemorrhoids without proper evaluation—colonoscopy should be performed to rule out proximal colonic pathology. 1, 3

Special Populations

Pregnant patients: Hemorrhoids occur in 80% during third trimester. 3 Safe treatments include fiber, fluids, psyllium husk, osmotic laxatives (polyethylene glycol or lactulose), and hydrocortisone foam. 1 Surgery is deferred until postpartum unless tissue necrosis occurs. 3

Immunocompromised patients (AIDS, neutropenia, uncontrolled diabetes) have 5-fold increased risk of necrotizing pelvic sepsis after any hemorrhoid procedure. 3