From the Guidelines
Internal hemorrhoids can be effectively treated with lifestyle changes and medical procedures, with the goal of reducing symptoms and improving quality of life. For mild cases, start with lifestyle changes including increasing fiber intake to 25-30 grams daily, drinking plenty of water (6-8 glasses), and avoiding straining during bowel movements 1. Over-the-counter treatments include topical creams containing hydrocortisone (0.5-1%) applied up to four times daily for a week to reduce inflammation and itching. Witch hazel pads or Preparation H can provide temporary relief. Warm sitz baths for 15 minutes, 2-3 times daily, help reduce pain and inflammation. For persistent symptoms, consider fiber supplements like psyllium husk (Metamucil) at 1 tablespoon mixed in water 1-3 times daily.
Medical Procedures
If these conservative measures fail after 1-2 weeks, medical procedures may be necessary, including:
- Rubber band ligation, which is most commonly used for first-, second-, or third-degree hemorrhoids 1
- Sclerotherapy
- Surgical removal for severe cases, which is associated with significantly more pain and complications than nonoperative techniques, and should be recommended only for a small minority of patients 1
Indications for Surgery
Indications for elective hemorrhoidectomy include:
- Failure of medical and nonoperative therapy
- Symptomatic third-degree, fourth-degree, or mixed internal and external hemorrhoids
- Symptomatic hemorrhoids in the presence of a concomitant anorectal condition that requires surgery
- Patient preference, after discussion of treatment options with the referring physician and surgeon 1
Key Considerations
- Rubber band ligation is a effective treatment for internal hemorrhoids, with success rates varying depending on the degree of hemorrhoids treated, length of follow-up, and criteria for success 1
- The most common complication of rubber band ligation is pain, which is reported in 5%–60% of treated patients 1
- Seek medical attention if you experience severe pain, heavy bleeding, or symptoms that don't improve with home treatment.
From the Research
Internal Hemorrhoid Treatment Options
- Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the first line of treatment for internal hemorrhoids 2
- Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, can also help alleviate symptoms 2
- If these initial treatments are unsuccessful, office-based procedures like rubber band ligation may be considered, as it has a lower failure rate than infrared photocoagulation 2
Comparison of Nonsurgical Treatments
- A comparative analysis of infrared coagulation, rubber band ligation, and injection sclerotherapy found that while similar numbers of patients were asymptomatic 12 months after treatment, rubber band ligation required fewer additional treatments due to recurrent symptoms 3
- However, rubber band ligation was associated with a higher incidence of posttreatment pain, whereas infrared coagulation had fewer and less severe complications 3
- The choice of treatment may depend on factors such as the grade of the hemorrhoid, patient preference, and the presence of comorbidities 2
Surgical Options
- Open or closed excisional hemorrhoidectomy can lead to greater surgical success rates, but may result in more pain and a prolonged recovery compared to office-based procedures 2
- Closed hemorrhoidectomy with diathermic or ultrasonic cutting devices may decrease bleeding and pain, and stapled hemorrhoidopexy can elevate grade III or IV hemorrhoids to their normal anatomic position 2
- Hemorrhoidal artery ligation may be a useful option for grade II or III hemorrhoids, as it may result in less pain and a quicker recovery 2