What are the treatment options for internal hemorrhoid relief?

Treatment Options for Internal Hemorrhoid Relief

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, which should be maintained for all patients regardless of hemorrhoid grade. 1

Conservative Management (First-Line for All Grades)

Dietary and Lifestyle Modifications:

• Increase fiber intake to 25-30 grams daily using bulk-forming agents like psyllium husk (5-6 teaspoonfuls with 600 mL water daily) 1
• Adequate fluid intake to soften stools and reduce straining 1
• Avoid prolonged straining during defecation 1
• Regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Options for Symptom Relief:

• Flavonoids (phlebotonics) are recommended to relieve bleeding, pain, and swelling by improving venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Topical analgesics (1.5-2% lidocaine ointment) provide symptomatic relief of local pain and itching, though long-term efficacy data are limited 1, 2
• Topical corticosteroids may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1, 2, 3

Office-Based Procedures (For Persistent Grade I-III Hemorrhoids)

When conservative management fails after 1-2 weeks, proceed to office-based interventions: 1

Rubber Band Ligation (Preferred First Procedural Intervention):

• Most effective office-based procedure with success rates of 70.5-89% depending on hemorrhoid grade 1
• More effective than sclerotherapy and requires fewer repeat treatments than infrared photocoagulation 1
• Can treat up to 3 hemorrhoids per session, though many practitioners limit to 1-2 columns at a time 1
• Band must be placed at least 2 cm proximal to the dentate line to avoid severe pain 1
• Repeated banding needed in up to 20% of patients 4
• Contraindicated in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) due to risk of necrotizing pelvic infection 1

Alternative Office-Based Procedures:

• Injection sclerotherapy: Suitable for first and second-degree hemorrhoids, with 70-85% short-term efficacy but only one-third achieve long-term remission 1, 4
• Infrared photocoagulation: 67-96% success rates for grade I-II hemorrhoids, but requires more repeat treatments 1
• Bipolar diathermy: 88-100% success rates for bleeding control in grade II hemorrhoids 1

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

Indications for Hemorrhoidectomy: 1

• Failure of medical and office-based therapy
• Symptomatic grade III or IV hemorrhoids
• Mixed internal and external hemorrhoids
• Anemia from hemorrhoidal bleeding
• Concomitant anorectal conditions requiring surgery (fissure, fistula)

Surgical Options:

• Conventional excisional hemorrhoidectomy (Ferguson closed or Milligan-Morgan open technique): Most effective treatment overall with lowest recurrence rate (2-10%), particularly for grade III-IV hemorrhoids 1, 4
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Stapled hemorrhoidopexy: Shows promising results with less postoperative pain and faster recovery, but lacks long-term follow-up data and has risk of rare severe complications (rectal perforation, pelvic sepsis) 1

Critical Pitfalls to Avoid

• Never attribute anemia or positive fecal occult blood to hemorrhoids without colonoscopy to rule out proximal colonic pathology 1
• Anal pain is generally NOT associated with uncomplicated internal hemorrhoids—its presence suggests other pathology such as anal fissure (occurs in up to 20% of patients with hemorrhoids), abscess, or thrombosis 1
• Avoid anal dilatation due to 52% incontinence rate at 17-year follow-up 1
• Avoid cryotherapy due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Never use corticosteroid preparations for more than 7 days due to risk of perianal tissue thinning 1, 3
• If symptoms worsen or fail to improve within 1-2 weeks, or if there is significant bleeding, severe pain, or fever, further evaluation is necessary 1

Treatment Algorithm by Grade

Grade I (bleeding, no prolapse):

• Conservative management → Rubber band ligation if persistent 1

Grade II (prolapse with spontaneous reduction):

• Conservative management → Rubber band ligation (preferred) or sclerotherapy/infrared photocoagulation if persistent 1

Grade III (prolapse requiring manual reduction):

• Conservative management → Rubber band ligation → Hemorrhoidectomy if failed 1

Grade IV (irreducible prolapse):

• Conventional excisional hemorrhoidectomy as definitive treatment 1