What is the management for internal hemorrhoids grade 3?

Management of Grade 3 Internal Hemorrhoids

For grade 3 internal hemorrhoids, rubber band ligation should be the first procedural intervention after conservative management fails, with surgical hemorrhoidectomy reserved for patients who do not respond to banding or prefer definitive treatment. 1

Initial Conservative Management (Always First-Line)

All grade 3 hemorrhoids should begin with conservative therapy regardless of eventual need for procedures: 1

• Increase dietary fiber to 25-30 grams daily (psyllium husk 5-6 teaspoonfuls with 600 mL water daily is highly effective) 1, 2
• Increase water intake to soften stool and reduce straining 1
• Avoid straining during defecation - this is critical as straining is the root cause of hemorrhoid progression 1, 2
• Limit defecation time to 3 minutes and aim for once-daily bowel movements 2

Phlebotonics (flavonoids) can relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 3

Topical treatments provide symptomatic relief but do not reduce hemorrhoidal swelling or protrusion: 1

• Topical analgesics (lidocaine) for pain and itching
• Corticosteroid creams for perianal irritation (maximum 7 days only to avoid mucosal thinning) 1

Office-Based Procedural Treatment

Rubber Band Ligation (Preferred First Procedure)

Rubber band ligation is the most effective office-based procedure for grade 3 hemorrhoids and should be attempted before surgery. 1, 3

Success rates: 70.5-89% depending on hemorrhoid grade and follow-up duration 1

Technique considerations: 1

• Place bands at least 2 cm proximal to dentate line to avoid severe pain
• Can be performed in office without anesthesia
• Limit to 1-2 hemorrhoid columns per session (though up to 3 can be banded)
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1

Complications: 1

• Pain (5-60% of patients) - usually minor, managed with sitz baths and over-the-counter analgesics
• Band slippage, prolapse/thrombosis of adjacent hemorrhoids (~5%)
• Severe bleeding when eschar sloughs (1-2 weeks post-treatment)
• Rare but serious: necrotizing pelvic sepsis (especially in immunocompromised patients)

Contraindications: 1

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes)
• Active thrombosis or acute prolapse

Alternative Office Procedures (Less Preferred)

• Infrared photocoagulation: 67-96% success for grade I-II hemorrhoids, but requires more repeat treatments 1
• Sclerotherapy: Suitable for grade I-II only, not recommended for grade 3 1

Surgical Management

Indications for Hemorrhoidectomy

Proceed directly to surgical hemorrhoidectomy for grade 3 hemorrhoids in these situations: 1

• Failure of conservative management and rubber band ligation
• Symptomatic grade 3 hemorrhoids with significant bleeding causing anemia 1
• Mixed internal and external hemorrhoids 1
• Concomitant conditions requiring surgery (fissure, fistula) 1
• Patient preference for definitive treatment 3

Surgical Options

Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the gold standard: 1, 3

• Lowest recurrence rate: 2-10% 1, 3
• Ferguson (closed) technique may have reduced postoperative pain and better wound healing compared to Milligan-Morgan (open) 1
• Major drawback: Significant postoperative pain requiring narcotic analgesics, with most patients unable to return to work for 2-4 weeks 1

Alternative surgical approaches (stapled hemorrhoidopexy, hemorrhoidal artery ligation): 1

• May have less postoperative pain and faster recovery
• Higher recurrence rates compared to conventional hemorrhoidectomy
• Can be considered for patient-specific situations

Critical Pitfalls to Avoid

• Never assume all anorectal symptoms are hemorrhoids - up to 20% of patients have concomitant anal fissures 1
• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy - hemorrhoids alone do not cause positive guaiac tests 1
• Never use anal dilation - 52% incontinence rate at 17-year follow-up 1
• Never use cryotherapy - causes prolonged pain, foul discharge, and requires more additional therapy 1
• Never perform simple incision and drainage of thrombosed components - leads to persistent bleeding and higher recurrence 1
• Never use corticosteroid creams >7 days - causes perianal mucosal thinning 1

Treatment Algorithm for Grade 3 Hemorrhoids

1. Start with 4-6 weeks of conservative management (fiber, fluids, lifestyle modification) 1, 3
2. If symptoms persist: Proceed to rubber band ligation 1, 3
3. If banding fails or recurs: Consider surgical hemorrhoidectomy 1, 3
4. If anemia, severe bleeding, or mixed disease present: Consider proceeding directly to hemorrhoidectomy 1

Special Considerations

Pregnancy: Hemorrhoids occur in ~80% of pregnant persons - use dietary fiber, fluids, psyllium husk, osmotic laxatives (polyethylene glycol/lactulose), and hydrocortisone foam (safe in third trimester) 1

Immunocompromised patients: Avoid rubber band ligation due to increased risk of necrotizing pelvic infection 1

When to reassess: If symptoms worsen or fail to improve within 1-2 weeks, or if significant bleeding, severe pain, or fever develop 1