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

Treatment of Internal Hemorrhoids

All internal hemorrhoids should begin with conservative management including increased dietary fiber (25-30g daily), adequate water intake, and avoidance of straining, with office-based procedures like rubber band ligation reserved for grades I-III that fail conservative therapy, and surgical hemorrhoidectomy for grades III-IV or when office procedures fail. 1

Initial Conservative Management (First-Line for All Grades)

• Increase dietary fiber intake to 25-30 grams daily using bulk-forming agents such as psyllium husk (5-6 teaspoonfuls with 600 mL water daily) to soften stool and reduce straining 1
• Ensure adequate fluid intake, particularly water, to promote soft, bulky stools and ease bowel movements 1
• Avoid straining during defecation through relaxation techniques and dietary adjustments 1
• Take regular sitz baths (warm water soaks) to reduce inflammation and discomfort 1

Pharmacological Adjuncts to Conservative Management

• Phlebotonics (flavonoids) relieve bleeding, pain, and swelling through improvement of venous tone, though symptom recurrence reaches 80% within 3-6 months after cessation 1, 2
• Topical corticosteroids may reduce local perianal inflammation but must be limited to ≤7 days maximum to avoid thinning of perianal and anal mucosa 1
• Topical analgesics (lidocaine 1.5-2% ointment) provide symptomatic relief of local pain and itching, though data supporting long-term efficacy are limited 1
• Suppository medications provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion 1

Office-Based Procedures (For Grades I-III After Conservative Failure)

Rubber Band Ligation (Preferred First Procedural Intervention)

Rubber band ligation is the most effective office-based procedure for grades I-III internal hemorrhoids, with success rates of 70.5-89%, and should be the first procedural intervention when conservative management fails. 1

• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerve afferents are absent above the anal transition zone 1
• Can be performed in an office setting without anesthesia using commercially available suction devices 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
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1, 2
• 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), typically minor and manageable with sitz baths and over-the-counter analgesics 1
• Other complications include abscess, urinary retention, band slippage, and prolapse/thrombosis of adjacent hemorrhoids (approximately 5%) 1
• Severe bleeding occasionally occurs when the eschar sloughs, typically 1-2 weeks after treatment 1
• Necrotizing pelvic sepsis is rare but serious, with increased risk in immunocompromised patients (uncontrolled AIDS, neutropenia, severe diabetes mellitus) 1

Alternative Office-Based Procedures

• Injection sclerotherapy is suitable for grades I-II hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage, 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 grades I-II hemorrhoids but requires more repeat treatments 1, 3
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

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

Indications for Hemorrhoidectomy

Surgical hemorrhoidectomy is indicated for failure of medical and office-based therapy, symptomatic grade III-IV hemorrhoids, mixed internal and external hemorrhoids, and anemia from hemorrhoidal bleeding. 1

• Conventional excisional hemorrhoidectomy is the most effective treatment overall, particularly for grade III-IV hemorrhoids, with low recurrence rates of 2-10% 1, 2
• Can be performed with open (Milligan-Morgan) or closed (Ferguson) techniques with no significant difference in outcomes 1
• Ferguson (closed) technique may offer slightly improved wound healing compared to open technique 1
• Success rate approaches 90-98% for grade III-IV hemorrhoids 1

Surgical Considerations and Complications

• Major drawback is 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%) 1
• Defects of the anal sphincter documented by ultrasonography and anorectal manometry in up to 12% of patients 1

Alternative Surgical Techniques

• Stapled hemorrhoidopexy shows promising results with less postoperative pain and faster return to normal activities, but lacks long-term follow-up data and has potential complications including rectal perforation, retroperitoneal sepsis, and pelvic sepsis 1, 4
• Hemorrhoidal artery ligation may be useful in grade II-III hemorrhoids with less pain and quicker recovery, and remains effective even without Doppler guidance 4, 3

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

Treatment Algorithm Based on Grade

Grade I (Bleeding, No Prolapse)

• Conservative management with fiber, fluids, and lifestyle modifications 1
• If persistent: rubber band ligation or sclerotherapy 1

Grade II (Prolapse with Spontaneous Reduction)

• Conservative management first 1
• If persistent: rubber band ligation (preferred), sclerotherapy, or infrared photocoagulation 1, 5

Grade III (Prolapse Requiring Manual Reduction)

• Conservative management trial first 1
• If persistent: rubber band ligation initially 1
• If failed office procedures: surgical hemorrhoidectomy 1

Grade IV (Irreducible Prolapse)

• Surgical hemorrhoidectomy (conventional excisional technique) 1
• Conservative management is not appropriate for grade IV hemorrhoids 1

Critical Pitfalls to Avoid

• Never attribute fecal occult blood or anemia to hemorrhoids without proper colonic evaluation, as hemorrhoids alone do not cause positive stool guaiac tests 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
• Anemia due to hemorrhoidal disease is rare (0.5 patients per 100,000 population), and when present with active bleeding, demands definitive surgical intervention 1
• 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
• 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

Special Populations

Pregnancy

• Hemorrhoids occur in approximately 80% of pregnant persons, more commonly during the third trimester 6
• Safe treatments include dietary fiber, adequate fluid intake, bulk-forming agents like psyllium husk, and osmotic laxatives (polyethylene glycol or lactulose) 6
• Hydrocortisone foam can be used safely in the third trimester with no adverse events compared to placebo 6
• For thrombosed hemorrhoids within 72 hours: surgical excision under local anesthesia; beyond 72 hours: conservative management 6