What is the recommended treatment for internal hemorrhoids?

Treatment of Internal Hemorrhoids

First-line treatment for all internal hemorrhoids is conservative management with increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining during defecation, regardless of hemorrhoid grade. 1

Initial Conservative Management (All Grades)

• Increase dietary fiber to 25-30 grams daily, which can be achieved with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL water daily 1
• Ensure adequate fluid intake to soften stool and reduce straining 1
• Avoid prolonged sitting on the toilet and straining during bowel movements 1
• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Warm sitz baths can reduce inflammation and discomfort 1

Topical Therapies for Symptom Relief

• Topical analgesics (lidocaine 1.5-2%) provide symptomatic relief of local pain and itching 1
• Topical corticosteroids may reduce perianal inflammation but MUST be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1
• Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

Office-Based Procedures (Grades I-III)

If conservative management fails after 4-6 weeks, rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids. 1, 2

Rubber Band Ligation (First-Line Procedural Treatment)

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and length of follow-up 1
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Can be performed in an office setting without anesthesia 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners prefer to limit treatment to 1-2 columns at a time 1
• Repeated banding is needed in up to 20% of patients 2

Complications of Rubber Band Ligation

• 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
• Other complications include band slippage, prolapse/thrombosis of adjacent hemorrhoids (approximately 5%), and severe bleeding when the eschar sloughs (typically 1-2 weeks after treatment) 1
• Necrotizing pelvic sepsis is rare but serious—avoid in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) 1

Alternative Office-Based Procedures

• Injection sclerotherapy is suitable for first and second-degree hemorrhoids, with short-term efficacy (weeks to months) in 70-85% of patients, but long-term remission occurs in only one-third 1, 2
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments than rubber band ligation 1, 2
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management (Grades III-IV or Failed Conservative/Office Therapy)

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and when concomitant conditions (fissure, fistula) require surgery. 1, 2

Conventional Excisional Hemorrhoidectomy

• This is the most effective treatment overall with the lowest recurrence rate (2-10%), particularly for grade III-IV hemorrhoids 1, 2
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques with no significant difference in outcomes 1
• Ferguson (closed) technique is associated with reduced postoperative pain and improved wound healing compared to Milligan-Morgan 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1

Alternative Surgical Options

• Stapled hemorrhoidopexy treats symptomatic internal hemorrhoids with reduced postoperative pain, shorter operation time and hospital stay, and faster recovery compared to excisional hemorrhoidectomy, but has a higher recurrence rate 1
• Hemorrhoidal artery ligation (HAL) with or without recto-anal repair (RAR) shows similar trends toward better tolerance but higher recurrence rates 1

Procedures to AVOID

• Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1
• Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1

Special Considerations

When Hemorrhoids Cause Anemia

• Hemorrhoidectomy is indicated for patients with anemia from hemorrhoidal bleeding, as this represents a critical threshold demanding definitive surgical intervention 1
• Active bleeding on anoscopy with low hemoglobin indicates substantial chronic blood loss requiring definitive control 1
• Never attribute anemia to hemorrhoids without proper evaluation—colonoscopy should be performed to rule out proximal colonic pathology 1

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 1
• Safe treatments include dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1
• Osmotic laxatives such as polyethylene glycol or lactulose can be used safely during pregnancy 1
• Hydrocortisone foam can be used safely in the third trimester with no adverse events 1

Critical Pitfalls to Avoid

• Do not assume all anorectal symptoms are due to hemorrhoids—other conditions like anal fissures (occur in up to 20% of patients with hemorrhoids), abscesses, or fistulas may coexist or be the primary cause 1
• Hemorrhoids alone do not cause positive stool guaiac tests—fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1
• Anal pain is generally NOT associated with uncomplicated internal hemorrhoids—its presence suggests other pathology such as anal fissure, abscess, or thrombosis 1
• If symptoms worsen or fail to improve within 1-2 weeks of treatment, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1
• Complete colonic evaluation by colonoscopy is indicated when bleeding is atypical for hemorrhoids, when no source is evident on anorectal examination, or when the patient has significant risk factors for colonic neoplasia 1