When is surgery indicated for patients with hemorrhoids (piles)?

When is Surgery Indicated for Hemorrhoids

Surgery is indicated for symptomatic third or fourth-degree hemorrhoids, failure of medical and non-operative therapy, mixed internal and external hemorrhoids, concomitant anorectal conditions requiring surgery (such as fissures or fistulas), and hemorrhoids causing anemia from chronic bleeding. 1

Grading System and Treatment Escalation

Internal hemorrhoids are classified into four grades that guide treatment decisions 1:

• Grade I: Bleeding without prolapse → Conservative management and office procedures
• Grade II: Prolapse with spontaneous reduction → Conservative management and office procedures
• Grade III: Prolapse requiring manual reduction → Office procedures or surgery
• Grade IV: Irreducible prolapse → Surgery

Specific Surgical Indications

Absolute Indications for Hemorrhoidectomy

• Symptomatic grade III or IV hemorrhoids that have failed conservative and office-based treatments 1
• Anemia from hemorrhoidal bleeding with active bleeding on anoscopy and low hemoglobin levels, as this represents substantial chronic blood loss requiring definitive control 1
• Mixed internal and external hemorrhoids with symptomatic external components that fail conservative therapy 1
• Acutely prolapsed, incarcerated, and thrombosed hemorrhoids should undergo either hemorrhoidectomy or excision of the external component with rubber band ligation of internal hemorrhoids 1
• Concomitant anorectal conditions (fissure, fistula, abscess) requiring surgical intervention 1

Relative Indications

• Failure of rubber band ligation or other office procedures after adequate trial (success rates for rubber band ligation vary from 70.5% to 89% depending on grade) 1
• Patient preference after thorough discussion of treatment options and realistic expectations 1
• Recurrent thrombosis or persistent symptoms despite conservative management 2

Critical Timing Considerations

Thrombosed External Hemorrhoids

• Within 72 hours of symptom onset: Complete excision under local anesthesia is recommended, providing faster pain relief and lower recurrence rates 1, 2
• Beyond 72 hours: Conservative management is preferred as natural resolution has typically begun; surgical excision is generally not necessary 1, 2
• Never perform simple incision and drainage of thrombosed hemorrhoids—this leads to persistent bleeding and higher recurrence rates; complete excision is required if surgical intervention is chosen 1, 2

Treatment Algorithm Before Surgery

First-Line Conservative Management (All Grades)

• Dietary modifications with 25-30 grams fiber daily (5-6 teaspoonfuls psyllium husk with 600 mL water) 1
• Adequate water intake to soften stool and reduce straining 1
• Topical treatments: 0.3% nifedipine with 1.5% lidocaine ointment every 12 hours for two weeks (92% resolution rate) 1, 2
• Short-term topical corticosteroids (≤7 days maximum) to avoid thinning of perianal and anal mucosa 1, 2

Office-Based Procedures (Grade I-III)

• Rubber band ligation: Most effective office procedure with 70.5-89% success rate for grades I-III 1
• Injection sclerotherapy: Suitable for grades I-II 1
• Infrared photocoagulation: 67-96% success for grades I-II 1

Surgery should be considered only after these measures have failed or are inappropriate for the hemorrhoid grade.

Surgical Options and Outcomes

Conventional Excisional Hemorrhoidectomy

• Most effective treatment overall with lowest recurrence rate of 2-10% 1, 3, 4
• Ferguson (closed) or Milligan-Morgan (open) techniques with comparable efficacy 1
• Major drawback: postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Complications include urinary retention (2-36%), bleeding (0.03-6%), anal stenosis (0-6%), infection (0.5-5.5%), and incontinence (2-12%) 5, 6

Alternative Surgical Approaches

• Stapled hemorrhoidopexy: Less postoperative pain, shorter hospital stay, faster recovery, but higher recurrence rate compared to conventional hemorrhoidectomy 5, 7
• Hemorrhoidal artery ligation (HAL): Better tolerance but higher recurrence rate 7

Critical Pitfalls to Avoid

• Never attribute anemia to hemorrhoids without colonoscopy to rule out proximal colonic pathology 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 need for additional therapy 1
• Do not perform surgery on patients with portal hypertension or cirrhosis without careful evaluation, as they may have anorectal varices rather than true hemorrhoids, and standard hemorrhoidectomy can cause life-threatening bleeding 1
• Immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes) have increased risk of necrotizing pelvic infection and require special consideration 1

Special Populations

• Pregnancy: Conservative management with fiber, fluids, and bulk-forming agents; hydrocortisone foam safe in third trimester 1
• Anticoagulated patients: Assess coagulation status and consider temporary adjustment in consultation with prescribing physician if surgery necessary 1