What is the treatment for a prolapsed hemorrhoid?

Treatment of Prolapsed Hemorrhoids

For prolapsed internal hemorrhoids, treatment depends on grade: grades I-II should receive conservative management followed by rubber band ligation if symptoms persist; grade III hemorrhoids can be treated with rubber band ligation or hemorrhoidectomy depending on severity; and grade IV hemorrhoids require surgical hemorrhoidectomy as definitive treatment. 1

Initial Conservative Management (All Grades)

Conservative therapy is the mandatory first-line approach for all hemorrhoid grades before considering procedural interventions 1:

• Increase dietary fiber intake to 25-30 grams daily, ideally through bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) 1
• Increase water intake to produce soft, bulky stools and reduce straining 1
• Avoid prolonged sitting on the toilet and straining during defecation 1
• Sitz baths (warm water soaks) reduce inflammation and discomfort 1

Pharmacological Adjuncts

• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 2, 1
• Topical analgesics (lidocaine) provide symptomatic relief of pain and itching 1
• Short-term topical corticosteroids (≤7 days maximum) may reduce perianal inflammation, but prolonged use causes mucosal thinning and must be avoided 1

Office-Based Procedures (Grades I-III)

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: 70.5-89% depending on hemorrhoid grade and follow-up duration 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can be performed in office without anesthesia 1
• Band must be placed ≥2 cm proximal to dentate line to avoid severe pain from somatic nerve stimulation 1
• Up to 3 hemorrhoids can be banded per session, though many practitioners limit to 1-2 columns 1

Common complications:

• Pain (5-60% of patients) - typically minor, managed with sitz baths and over-the-counter analgesics 1
• Band slippage, prolapse/thrombosis of adjacent hemorrhoids (~5%) 1
• Severe bleeding when eschar sloughs (1-2 weeks post-procedure) 1
• Necrotizing pelvic sepsis (rare but serious) - increased risk in immunocompromised patients 1

Alternative Office Procedures

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

Surgical Management

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for: 1

• Failure of medical and office-based therapy
• Symptomatic grade III-IV hemorrhoids
• Mixed internal and external hemorrhoids
• Concomitant conditions requiring surgery (fissure, fistula)
• Anemia from hemorrhoidal bleeding (represents critical threshold demanding definitive intervention) 1

Surgical Techniques

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard with recurrence rates of only 2-10% 1, 2:

• Most effective long-term treatment, particularly for grade III-IV hemorrhoids 1
• Ferguson (closed) technique involves primary wound closure and may reduce postoperative pain compared to open technique 1
• Major drawback: postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Alternative surgical options:

• Stapled hemorrhoidopexy: Faster recovery but higher recurrence rate 2
• Hemorrhoidal artery ligation: Less pain, quicker recovery, but limited long-term data 3

Procedures to Avoid

• Anal dilatation should never be performed - 52% incontinence rate at 17-year follow-up with sphincter injuries 1
• Cryotherapy should be avoided - prolonged pain, foul-smelling discharge, greater need for additional therapy 1

Management of Thrombosed External Hemorrhoids

For thrombosed external hemorrhoids presenting within 72 hours: complete excision under local anesthesia provides fastest pain relief and lowest recurrence 1, 2:

• Never perform simple incision and drainage - leads to persistent bleeding and higher recurrence 1
• Excision can be performed as outpatient procedure with low complication rates 1

For presentation >72 hours after onset: Conservative management is preferred 1:

• Stool softeners
• Oral analgesics (acetaminophen or ibuprofen) 1
• Topical 0.3% nifedipine with 1.5% lidocaine applied every 12 hours for 2 weeks achieves 92% resolution versus 45.8% with lidocaine alone 1
• Pain typically resolves spontaneously after 7-10 days 4

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1
• Anal pain is NOT typical of uncomplicated hemorrhoids - suggests thrombosis, anal fissure (present in 20% of hemorrhoid patients), or abscess 1
• Do not use corticosteroid creams >7 days - causes perianal tissue thinning and increased injury risk 1
• Do not delay definitive treatment when active bleeding has caused anemia - natural history is continued blood loss 1

Special Populations

Pregnancy: 1

• Hemorrhoids occur in ~80% of pregnant persons, more common in third trimester
• Safe treatments: dietary fiber, adequate fluids, bulk-forming agents (psyllium)
• Osmotic laxatives (polyethylene glycol, lactulose) safe during pregnancy
• Hydrocortisone foam safe in third trimester with no adverse events versus placebo