What are the treatment options for internal hemorrhoids?

Treatment of Internal Hemorrhoids

Conservative management with increased dietary fiber and water intake is the mandatory first-line treatment for all grades of internal hemorrhoids, followed by rubber band ligation for persistent grade I-III disease, and excisional hemorrhoidectomy for grade III-IV disease unresponsive to less invasive approaches. 1, 2

Initial Conservative Management (Required for All Patients)

• Increase dietary fiber intake to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1
• Ensure adequate water intake (at least 8 glasses daily) to complement fiber supplementation 1
• Avoid prolonged straining during defecation, which exacerbates hemorrhoidal prolapse 1, 2
• Flavonoids (phlebotonics) provide symptomatic relief for bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2

Topical Symptomatic Relief

• Topical analgesics containing lidocaine provide short-term relief of pain and itching, though long-term efficacy data are limited 1, 3
• Topical corticosteroid creams may reduce perianal inflammation but MUST be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1, 3
• Regular sitz baths (warm water soaks) reduce inflammation and discomfort 1

Office-Based Procedures for Persistent Grade I-III Disease

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails. 1

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and length of follow-up 1
• More effective than sclerotherapy and requires fewer additional treatments than infrared photocoagulation 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 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
• Repeated banding is needed in up to 20% of patients 2

Complications of Rubber Band Ligation

• Pain is the most common complication (5-60% of patients) but is typically minor and manageable with sitz baths and over-the-counter analgesics 1
• Severe bleeding occasionally occurs when the eschar sloughs, typically 1-2 weeks after treatment 1
• Necrotizing pelvic sepsis is rare but serious—avoid in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) 1

Alternative Office-Based Procedures (Second-Line)

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 2
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1, 2
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management for Grade III-IV Disease

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated when:

• Medical and office-based therapy have failed 1
• Symptomatic grade III-IV hemorrhoids are present 1, 2
• Mixed internal and external hemorrhoids exist 1
• Concomitant conditions (fissure, fistula) require surgery 1
• Anemia from hemorrhoidal bleeding has developed 1

Conventional Excisional Hemorrhoidectomy (Gold Standard)

• Conventional excisional hemorrhoidectomy is the most effective treatment overall with recurrence rates of only 2-10% 1, 2
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques with no significant difference in outcomes 1
• Ferguson (closed) technique is associated with reduced postoperative pain and improved wound healing compared to open technique 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Alternative Surgical Options

• Stapled hemorrhoidopexy has faster postoperative recovery (9-14 days) but higher recurrence rates than conventional hemorrhoidectomy 2, 4
• Hemorrhoidal artery ligation may cause less pain with faster recovery but has higher recurrence rates 4

Treatment Algorithm Based on Hemorrhoid Grade

Grade I (Bleeding Without Prolapse)

1. Conservative management with fiber, fluids, lifestyle modifications 1
2. If persistent: Rubber band ligation or injection sclerotherapy 1, 2

Grade II (Prolapse with Spontaneous Reduction)

1. Conservative management initially 1
2. If persistent: Rubber band ligation (first choice) 1, 2
3. Alternative: Infrared photocoagulation or sclerotherapy 1

Grade III (Prolapse Requiring Manual Reduction)

1. Conservative management trial 1
2. Rubber band ligation for initial procedural approach 1, 2
3. If unsuccessful: Excisional hemorrhoidectomy or stapled hemorrhoidopexy 1, 2

Grade IV (Irreducible Prolapse)

1. Conventional excisional hemorrhoidectomy (Ferguson or Milligan-Morgan technique) is the gold standard 1
2. Alternative: Stapled hemorrhoidopexy (faster recovery, higher recurrence) 2

Critical Pitfalls to Avoid

• Never attribute fecal occult blood or anemia to hemorrhoids until the colon is adequately evaluated—hemorrhoids alone do not cause positive stool guaiac tests 5, 1
• Anal pain is generally NOT associated with uncomplicated internal hemorrhoids—its presence suggests other pathology such as anal fissure (present in up to 20% of hemorrhoid patients), abscess, or thrombosis 5, 1
• Avoid anal dilatation—it causes 52% incontinence rate at 17-year follow-up and sphincter injuries 1
• Avoid cryotherapy due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Never use corticosteroid creams for more than 7 days as prolonged use causes perianal tissue thinning 1, 3
• Complete colonic evaluation by colonoscopy is indicated when bleeding is atypical for hemorrhoids, when no source is evident on anorectal examination, or when the patient has significant risk factors for colonic neoplasia 5

Special Considerations

• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) and responds to hemorrhoidectomy 5
• In pregnant patients, safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, osmotic laxatives (polyethylene glycol or lactulose), and hydrocortisone foam in the third trimester 1
• Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1