What is the management of grade 3 hemorrhoids (internal hemorrhoids with prolapse and reduction)

From the Guidelines

Rubber band ligation is the most effective treatment for grade 3 hemorrhoids, with a high success rate and low recurrence rate, as evidenced by the American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids 1. Management of grade 3 hemorrhoids typically requires more aggressive treatment than lower grades due to their prolapsing nature that requires manual reduction. Initial management includes conservative measures such as:

• Increasing dietary fiber (25-30g daily)
• Adequate fluid intake
• Sitz baths for 10-15 minutes several times daily Topical treatments like hydrocortisone cream or suppositories can help reduce inflammation and discomfort. For pain management, acetaminophen or NSAIDs may be used. However, since grade 3 hemorrhoids often don't respond adequately to these measures alone, procedural interventions are usually necessary. Other office-based procedures include:
• Sclerotherapy (injection of a solution to shrink the hemorrhoid)
• Infrared coagulation For more severe or persistent cases, surgical options like hemorrhoidectomy (surgical removal) or stapled hemorrhoidopexy may be required. These procedures are more definitive but involve longer recovery periods. The choice of treatment depends on the patient's symptoms, comorbidities, and preferences, with the goal of reducing prolapse, bleeding, and discomfort while preventing recurrence, as recommended by the American Gastroenterological Association medical position statement on diagnosis and treatment of hemorrhoids 1 and supported by the WSES-AAST guidelines for anorectal emergencies 1.

From the Research

Hemorrhoid Grade 3 Management

• Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the initial treatment approach for hemorrhoids 2.
• Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, are also recommended as part of the initial therapy 2.
• If these initial treatments are unsuccessful, office-based treatment with rubber band ligation is the preferred next step for grades I to III internal hemorrhoids, including grade 3, due to its lower failure rate compared to infrared photocoagulation 2.
• For grade III hemorrhoids, minimally invasive treatment options such as mucopexy with or without mucosal resection and hemorrhoid artery ligation have been proposed, aiming to correct the underlying pathophysiological mechanisms with less pain and quicker recovery 3.
• Rubber band ligation is recommended as the initial mode of therapy for grades 1 to 3 hemorrhoids, with hemorrhoidectomy reserved for patients who fail to respond to rubber band ligation due to its association with more complications and pain 4.
• Stapled hemorrhoidopexy is another option for grade III hemorrhoids, which elevates the hemorrhoids to their normal anatomic position by removing a band of proximal mucosal tissue, but it has potential postoperative complications 2.
• The choice of treatment should consider factors such as the degree of discomfort, bleeding, comorbidities, and patient preference, alongside the grade of the hemorrhoid 2.