What is the treatment for internal hemorrhoids?

From the Guidelines

Rubber band ligation is the recommended initial procedure for treating internal hemorrhoids due to its higher efficacy rate compared to other nonoperative treatments like sclerotherapy and infrared photocoagulation. This recommendation is based on the findings of MacRae et al. 1, which concluded that rubber band ligation was more effective than sclerotherapy and less likely to require additional therapy than either sclerotherapy or infrared photocoagulation, despite being more likely to cause pain.

Some key points to consider when treating internal hemorrhoids include:

• The use of bipolar diathermy, direct-current electrotherapy, and infrared photocoagulation, which rely on the coagulation, occlusion, and obliteration or sclerosis of the hemorrhoidal vascular pedicle above the level of the anal transition zone 1.
• The success rates of these treatments, with rubber band ligation having a higher rate of efficacy, but also a higher incidence of pain compared to other treatments like infrared photocoagulation 1.
• The importance of considering the severity of the hemorrhoids when choosing a treatment, with medical therapy being most appropriate for first-degree hemorrhoids, and more invasive procedures being necessary for larger or more persistent hemorrhoids 1.

In terms of specific treatment options, the following are available:

• Rubber band ligation, which involves placing small bands around the hemorrhoids to cut off circulation.
• Sclerotherapy, which involves injecting a solution to shrink the hemorrhoid.
• Infrared coagulation, which uses infrared radiation to coagulate the hemorrhoidal tissue.
• Bipolar diathermy, direct-current electrotherapy, which use electrical current to coagulate the hemorrhoidal tissue.

It's worth noting that the American Gastroenterological Association recommends a stepped approach to treating hemorrhoids, starting with conservative measures such as increasing fiber intake and using topical treatments, and progressing to more invasive procedures as needed 1.

From the Research

Internal Hemorrhoids Treatment

• Internal hemorrhoids typically present with prolapse or painless rectal bleeding 2
• Medical therapy should be initiated with stool softeners plus local therapy to relieve swelling and symptoms 2
• Rubber band ligation is the treatment of choice for grades 1 and 2 hemorrhoids 2, 3
• For grade 3 hemorrhoids, rubber band ligation, excisional hemorrhoidectomy, or stapled hemorrhoidopexy can be performed 2, 3
• Excisional hemorrhoidectomy or stapled hemorrhoidopexy is recommended for treatment of grade 4 hemorrhoids 2, 3
• Office-based treatment of grades I to III internal hemorrhoids with rubber band ligation is the preferred next step if medical management is unsuccessful 3
• Polidocanol sclerotherapy may be associated with higher therapeutic success in patients with symptomatic grade I-III internal hemorrhoids compared to rubber band ligation 4

Treatment Options

• Medical management: stool softeners, topical over-the-counter preparations, topical nitroglycerine 3
• Dietary modifications: increased fiber and water intake 3
• Behavioral therapies: sitz baths 3
• Office-based procedures: rubber band ligation, infrared photocoagulation, polidocanol sclerotherapy 3, 4
• Surgical procedures: excisional hemorrhoidectomy, stapled hemorrhoidopexy, hemorrhoidal artery ligation 2, 5, 3

Postoperative Care

• Postoperative pain from excisional hemorrhoidectomy can be treated with nonsteroidal anti-inflammatory drugs, narcotics, fiber supplements, and topical antispasmodics 2
• Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain 3
• Stapled hemorrhoidopexy has a faster postoperative recovery, but a higher recurrence rate 2, 3