What are the treatment options for a patient with internal hemorrhoids?

Treatment of Internal Hemorrhoids

Conservative management with increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining is the mandatory first-line treatment for all grades of internal hemorrhoids, regardless of severity. 1, 2

Initial Conservative Management (Required for All Patients)

All patients with internal hemorrhoids must begin with dietary and lifestyle modifications before considering any procedural intervention:

• Increase dietary fiber to 25-30 grams daily, which can be achieved with 5-6 teaspoonfuls of psyllium husk mixed with 600 mL of water daily 1, 2
• Ensure adequate fluid intake to soften stools and reduce straining during defecation 1, 2
• Avoid prolonged straining during bowel movements by using relaxation techniques and proper bathroom habits 1, 2
• Consider phlebotonics (flavonoids) to relieve bleeding, pain, and swelling, though be aware that symptom recurrence reaches 80% within 3-6 months after cessation 1, 3

Topical Treatments for Symptom Relief

• Topical analgesics (such as 5% lidocaine) provide symptomatic relief of local pain and itching 1, 3
• Short-term topical corticosteroids (≤7 days maximum) can reduce perianal inflammation, but must never exceed 7 days to avoid thinning of perianal and anal mucosa 1, 2

Office-Based Procedures (When Conservative Management Fails)

Rubber Band Ligation (First-Line Procedural Treatment)

Rubber band ligation is the most effective office-based procedure and should be the first procedural intervention for persistent grade I-III internal hemorrhoids after conservative management fails. 1, 3

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

Common complications:

• Pain (5-60% of patients, typically minor and manageable with sitz baths and over-the-counter analgesics) 1
• Band slippage, prolapse/thrombosis of adjacent hemorrhoids (~5%) 1
• Severe bleeding when eschar sloughs (typically 1-2 weeks after treatment) 1

Contraindications:

• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic infection 1

Alternative Office-Based Procedures

• Injection sclerotherapy is suitable for first and second-degree hemorrhoids, causing fibrosis and tissue shrinkage, with 70-85% short-term success but only one-third achieving long-term remission 1, 3
• Infrared photocoagulation has 67-96% success rates for grade I-II hemorrhoids but requires more repeat treatments 1, 3
• Bipolar diathermy achieves 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management

Indications for Hemorrhoidectomy

Conventional excisional hemorrhoidectomy is indicated when: 1, 2

• Medical and office-based therapy have failed
• Symptomatic grade III or IV hemorrhoids are present
• Mixed internal and external hemorrhoids exist
• Concomitant anorectal conditions (fissure, fistula) require surgery
• Anemia has developed from hemorrhoidal bleeding 1

Surgical Approach

Conventional excisional hemorrhoidectomy (Milligan-Morgan open or Ferguson closed technique) is the most effective treatment overall, particularly for third-degree hemorrhoids, with a recurrence rate of only 2-10%. 1, 2, 3

• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 1
• Success rates approach 90-98% with low recurrence 1
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Recovery typically takes 9-14 days 3

Critical Pitfalls to Avoid

• Never attribute fecal occult blood or anemia to hemorrhoids until the colon is adequately evaluated with colonoscopy 1, 2
• 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) 1
• Never perform anal dilatation—it causes sphincter injuries and results in 52% incontinence rate at 17-year follow-up 1
• Avoid cryotherapy—it causes prolonged pain, foul-smelling discharge, and greater need for additional therapy 1
• Do not use corticosteroid creams for more than 7 days—prolonged use causes thinning of perianal and anal mucosa 1, 2

When to Escalate Care

• If symptoms worsen or fail to improve within 1-2 weeks of treatment, further evaluation is necessary 1
• Significant bleeding, severe pain, or fever require immediate reassessment 1
• Anemia due to hemorrhoidal disease is rare (0.5 patients/100,000 population) and demands definitive surgical intervention 1