What is the proper management plan for a patient with anal swelling and bleeding, where the swelling is protruded but not reduced except manually?

Management of Grade III Internal Hemorrhoids

For a patient with anal swelling and bleeding where the prolapsed tissue requires manual reduction (Grade III internal hemorrhoids), the proper management is hemorrhoidectomy (Option A). 1, 2, 3

Clinical Classification and Rationale

This patient presents with Grade III internal hemorrhoids, defined by prolapse beyond the anus requiring manual reduction. 1, 2 This classification is critical because it determines the treatment algorithm:

• Grade I-II hemorrhoids: Prolapse into anal canal or spontaneously reduce → office-based procedures appropriate 1, 2
• Grade III hemorrhoids requiring manual reduction: Surgical hemorrhoidectomy is the definitive treatment 1, 3
• Grade IV (irreducible) hemorrhoids: Urgent surgical intervention 1

Why Hemorrhoidectomy is the Correct Answer

Excisional hemorrhoidectomy achieves the lowest recurrence rates (2-10%) for Grade III disease, with durable long-term outcomes. 1 While recovery takes 9-14 days, this is the trade-off for definitive treatment in patients with prolapsing disease requiring manual reduction. 1

The Japanese Practice Guidelines specifically recommend ligation and excision (LE) for Grade III and IV internal and external hemorrhoids as the standard surgical approach. 3

Why the Other Options Are Inadequate

Rubber Band Ligation (Option B)

• Rubber band ligation is only appropriate for Grade I-III hemorrhoids with minimal prolapse, not those requiring manual reduction. 4, 1
• While it resolves symptoms in 89% of patients initially, repeated banding is needed in up to 20% of cases. 1
• The failure rate is unacceptably high for Grade III disease with significant prolapse requiring manual reduction. 2

Sclerotherapy (Option C)

• Sclerotherapy is only efficacious short-term (weeks to months) in 70-85% of patients, with long-term remission in only one-third. 1
• This high failure rate makes it unsuitable for Grade III prolapsing hemorrhoids. 1
• It is reserved for smaller, non-prolapsing internal hemorrhoids. 3

Laxatives (Option D)

• Dietary modification with increased fiber and water is first-line treatment only, not definitive management for Grade III disease. 1, 2
• While stool softeners prevent symptom exacerbation, they do not address the anatomic prolapse requiring manual reduction. 2
• This would be appropriate initial therapy for Grade I-II disease, but inadequate for Grade III. 1

Important Clinical Pitfalls

Do not attempt office-based procedures for Grade III hemorrhoids requiring manual reduction - these patients need surgical hemorrhoidectomy for definitive treatment. 1, 3 The common mistake is attempting rubber band ligation in Grade III disease, which leads to high failure rates and patient dissatisfaction. 1, 2

Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain compared to conventional techniques. 2 Consider these advanced surgical approaches when available to optimize patient outcomes. 2