What are the treatment options for internal hemorrhoids?

Treatment of Internal Hemorrhoids

All internal hemorrhoids should begin with conservative management consisting of 25-30 grams of dietary fiber daily plus increased water intake, and if this fails after 1-2 weeks, rubber band ligation is the first-line procedural intervention for grades I-III disease, while excisional hemorrhoidectomy is reserved for grade IV hemorrhoids or when conservative and office-based treatments have failed. 1, 2

Initial Conservative Management (First-Line for All Grades)

• Increase dietary fiber to 25-30 grams daily combined with increased water intake to soften stool and reduce straining—this is the cornerstone of treatment with the strongest evidence for reducing bleeding 1, 2
• Add bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) if dietary modifications alone are insufficient 2
• Instruct patients to avoid straining during defecation, as this is a primary causative factor 2
• Consider flavonoids (phlebotonics) for acute bleeding control, which improve venous tone and reduce bleeding, pain, and swelling, though 80% of patients experience symptom recurrence within 3-6 months after stopping 1, 3

Critical Pitfall: Never attribute anemia or positive fecal occult blood tests to hemorrhoids without colonoscopy to exclude proximal colonic pathology—hemorrhoids alone do not cause positive guaiac tests 1, 2

Office-Based Procedures (When Conservative Management Fails After 1-2 Weeks)

Rubber Band Ligation (First-Line Procedural Treatment)

• Rubber band ligation is the preferred office-based procedure for persistent grades I-III internal hemorrhoids with success rates of 70.5-89% depending on hemorrhoid grade 1, 2, 3
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerves are absent above this level 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
• Rubber band ligation is more effective than sclerotherapy and requires fewer repeat treatments than sclerotherapy or infrared photocoagulation 1, 2
• 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 can occur when the eschar sloughs 1-2 weeks after treatment 1

Contraindication: Avoid rubber band ligation in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to increased risk of necrotizing pelvic sepsis 1

Alternative Office-Based Procedures (Less Effective)

• Injection sclerotherapy is suitable for grades I-II hemorrhoids with 70-85% short-term success, but long-term remission occurs in only one-third of patients 2, 3
• Infrared photocoagulation has 67-96% success rates for grades I-II hemorrhoids but requires more repeat treatments 2, 4
• Bipolar diathermy achieves 88-100% success for bleeding control in grade II hemorrhoids 2

Surgical Management

Indications for Hemorrhoidectomy

• Excisional hemorrhoidectomy is indicated for:
  • Grade IV hemorrhoids 2, 3
  • Grade III hemorrhoids that fail office-based procedures 2, 3
  • Mixed internal and external hemorrhoids 2
  • Hemorrhoidal bleeding causing anemia 1, 2
  • Concomitant anorectal conditions (fissure, fistula) requiring surgery 2

Surgical Technique and Outcomes

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique) is the most effective treatment overall with 2-10% recurrence rate 1, 2, 3
• Ferguson closed technique may have reduced postoperative pain and faster wound healing compared to Milligan-Morgan open technique 2, 5
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 2
• Stapled hemorrhoidopexy may result in less postoperative pain and faster recovery but has higher recurrence rates 5, 4

Procedures to Avoid:

• Never perform anal dilatation—it causes 52% incontinence rate at 17-year follow-up due to sphincter injuries 1, 2
• Avoid cryotherapy—it causes prolonged pain, foul-smelling discharge, and requires more additional therapy 1, 2

Treatment Algorithm by Grade

Grade I (Bleeding Without Prolapse)

1. Conservative management with fiber and water intake 1, 2
2. Add flavonoids if bleeding persists 1
3. Rubber band ligation if conservative measures fail after 1-2 weeks 2, 3

Grade II (Prolapse With Spontaneous Reduction)

1. Conservative management for 1-2 weeks 1, 2
2. Rubber band ligation as first procedural intervention 2, 3
3. Consider sclerotherapy or infrared photocoagulation as alternatives 2, 4

Grade III (Prolapse Requiring Manual Reduction)

1. Trial of conservative management 2
2. Rubber band ligation as first procedural approach 2, 3
3. Excisional hemorrhoidectomy if office procedures fail or patient preference 2, 3

Grade IV (Irreducible Prolapse)

1. Excisional hemorrhoidectomy is first-line treatment 2, 3
2. Conservative management is inadequate for this grade 2

Special Situations

Hemorrhoids With Anemia

• Hemorrhoidectomy is indicated when hemorrhoidal bleeding has caused anemia—this represents a critical threshold requiring definitive surgical intervention 2
• Do not delay definitive treatment, as the natural history will be continued blood loss 1
• Blood transfusion may be needed preoperatively if hemoglobin is critically low 2
• Always perform colonoscopy to rule out proximal colonic pathology before attributing anemia to hemorrhoids 1, 2

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly in the third trimester 2
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 2
• Osmotic laxatives (polyethylene glycol or lactulose) can be used safely 2
• Hydrocortisone foam can be used safely in the third trimester 2

Topical Agents (Adjunctive Symptom Relief Only)

• Over-the-counter topical preparations lack strong evidence for effectiveness and should not be relied upon as primary treatment for significant bleeding 1
• Topical analgesics (lidocaine) provide symptomatic relief of pain and itching but do not reduce hemorrhoidal swelling, bleeding, or protrusion 2
• Topical corticosteroids may reduce local inflammation but must be limited to ≤7 days to avoid thinning of perianal and anal mucosa 1, 2
• Topical nifedipine 0.3% with lidocaine 1.5% applied every 12 hours for two weeks achieves 92% resolution for thrombosed hemorrhoids (primarily for pain relief, not bleeding control) 1

Key Pitfalls to Avoid

• Never assume all anorectal symptoms are due to hemorrhoids—up to 20% of patients have concomitant anal fissures 2
• Do not use corticosteroid creams for more than 7 days due to risk of perianal tissue thinning 1, 2
• Avoid relying on suppositories as primary treatment—they lack evidence for reducing swelling, bleeding, or protrusion 2
• Do not delay colonoscopy in patients at risk for colorectal cancer (age >50 years) even if hemorrhoids are visible 6
• Anal pain is generally not associated with uncomplicated internal hemorrhoids—its presence suggests thrombosis, fissure, or abscess 2, 7