What are the treatment options for internal hemorrhoids (internal hemorrhoids) on an outpatient basis?

Outpatient Treatment of Internal Hemorrhoids

For internal hemorrhoids, begin with conservative management (fiber, fluids, lifestyle modifications) for all grades, then escalate to rubber band ligation for persistent grade I-III disease, reserving excisional hemorrhoidectomy for grade III-IV disease that fails office procedures or presents with complications like anemia. 1

Initial Conservative Management (First-Line for All Grades)

All patients with internal hemorrhoids should start with dietary and lifestyle modifications regardless of grade. 1

• Increase fiber intake to 25-30 grams daily and water intake to soften stool and reduce straining 1
• Avoid prolonged straining during defecation 1
• Consider bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) 1

Pharmacological Adjuncts

• Phlebotonics (flavonoids/diosmin) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Topical analgesics (lidocaine) provide symptomatic relief of local pain and itching, though long-term efficacy data are limited 1
• Short-term topical corticosteroids (≤7 days) may reduce perianal inflammation but must be limited to avoid mucosal thinning 1

Important caveat: Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1. They are adjunctive only, not curative.

Office-Based Procedures (Second-Line for Grade I-III)

If conservative management fails after 1-2 weeks, proceed to office-based procedures. 1

Rubber Band Ligation (Preferred First Procedural Intervention)

Rubber band ligation is the most effective office-based procedure for grade I-III internal hemorrhoids, with success rates of 70.5-89%. 1, 2

• 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 1
• Up to 3 hemorrhoids can be banded per session, though many practitioners limit to 1-2 columns 1

Complications to monitor:

• Pain (5-60% of patients) - typically minor, managed with sitz baths and over-the-counter analgesics 1
• Severe bleeding when eschar sloughs (1-2 weeks post-procedure) 1
• Rare but serious: necrotizing pelvic sepsis (increased risk in immunocompromised patients) 1

Contraindications: Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing infection 1

Alternative Office Procedures (If Rubber Band Ligation Unavailable or Failed)

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

Surgical Management (Third-Line or Initial for Grade IV)

Surgical hemorrhoidectomy is indicated for:

• Failure of medical and office-based therapy 1
• Symptomatic grade III-IV hemorrhoids 1
• Mixed internal and external hemorrhoids 1
• Anemia from hemorrhoidal bleeding 1
• Concomitant anorectal conditions requiring surgery 1

Conventional Excisional Hemorrhoidectomy (Gold Standard)

Excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) achieves the lowest recurrence rate (2-10%) and is most effective for grade III-IV disease. 1, 2

• Ferguson (closed) technique associated with reduced postoperative pain and faster wound healing 1
• Major drawback: postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Success rate approaches 90-98% for complicated disease 1

Procedures to avoid:

• Anal dilatation: Never perform - 52% incontinence rate at 17-year follow-up 1
• Cryotherapy: Rarely used due to prolonged pain, foul-smelling discharge, and need for additional therapy 1

Treatment Algorithm by Grade

Grade I (Bleeding, No Prolapse)

1. Conservative management (fiber, fluids, lifestyle) 1
2. If persistent: Rubber band ligation or sclerotherapy 1

Grade II (Prolapse with Spontaneous Reduction)

1. Conservative management 1
2. If persistent: Rubber band ligation (preferred) 1
3. Alternative: Sclerotherapy or infrared photocoagulation 1

Grade III (Prolapse Requiring Manual Reduction)

1. Conservative management trial 1
2. Rubber band ligation for persistent symptoms 1
3. Excisional hemorrhoidectomy if office procedures fail or patient preference 1

Grade IV (Irreducible Prolapse)

1. Excisional hemorrhoidectomy is first-line treatment 1, 2
2. Office-based procedures are not appropriate 3

Critical Pitfalls to Avoid

Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy - hemorrhoids alone do not cause positive stool guaiac tests 1, 3. Proximal colonic pathology must be ruled out first.

Significant anal pain is NOT typical of uncomplicated internal hemorrhoids - its presence suggests alternative pathology like anal fissure (occurs in up to 20% of hemorrhoid patients), abscess, or thrombosis 1, 4.

Do not delay definitive treatment when active bleeding has caused anemia - these patients require hemorrhoidectomy, not conservative management 1, 3.

Corticosteroid creams must be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1.

When to Refer

• Grade IV hemorrhoids (always require surgical evaluation) 3
• Anemia from hemorrhoidal bleeding 3
• Failure of conservative management after 1-2 weeks 3
• Persistent symptoms after multiple office procedures 3
• Mixed internal and external hemorrhoids 3
• Concomitant anorectal conditions (fissure, fistula) 3
• Immunocompromised patients (lower threshold for complications) 3