What is the recommended management for internal hemorrhoids?

Treatment for Internal Hemorrhoids

All internal hemorrhoids should begin with conservative management—increased dietary fiber (25-30 g/day), adequate water intake, and avoidance of straining—then escalate to rubber band ligation for persistent grade I-III disease, reserving surgical hemorrhoidectomy for grade III-IV disease that fails office-based procedures. 1, 2

First-Line Conservative Management (All Grades)

Dietary and lifestyle modifications are mandatory initial therapy regardless of hemorrhoid grade. 1, 2

• Increase dietary fiber to 25-30 grams daily using psyllium husk (5-6 teaspoons with 600 mL water daily) to produce soft, bulky stools and reduce straining 1, 2
• Ensure adequate fluid intake to complement fiber supplementation and prevent constipation 1, 2
• Avoid straining during defecation, the primary factor worsening hemorrhoidal disease 1, 2
• Sitz baths (warm water soaks) reduce inflammation and provide symptomatic relief 1

Pharmacological Adjuncts

Flavonoids (phlebotonics) are first-line oral agents that improve venous tone and reduce bleeding, pain, and swelling, though 80% of patients experience symptom recurrence within 3-6 months after cessation 1, 2, 3

Topical agents provide symptomatic relief but lack strong evidence for reducing hemorrhoidal swelling, bleeding, or protrusion: 1

• Topical analgesics (lidocaine 1.5-2% cream) for local pain and itching, though long-term efficacy data are limited 1, 2
• Corticosteroid creams may reduce perianal inflammation but must be limited to ≤7 days maximum to avoid mucosal thinning 1, 2
• Suppository medications provide symptomatic relief only; no strong evidence supports reduction of hemorrhoidal swelling, bleeding, or protrusion 1

Office-Based Procedures (Grade I-III Disease)

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, 4

Rubber Band Ligation

• Success rates range from 70.5% to 89% depending on hemorrhoid grade and follow-up duration 1, 3
• More effective than sclerotherapy and requires fewer additional treatments than sclerotherapy or infrared photocoagulation 1, 4
• The band must be placed at least 2 cm proximal to the dentate line to avoid severe pain, as somatic sensory nerves are absent above the anal transition zone 1
• Up to 3 hemorrhoids can be banded in a single session, though many practitioners limit treatment to 1-2 columns at a time 1
• Pain is the most common complication (5-60% of patients) but is typically minor and manageable with sitz baths and over-the-counter analgesics 1
• Repeated banding is needed in up to 20% of patients for recurrent symptoms 3

Alternative Office-Based Procedures (Less Effective)

• Injection sclerotherapy is suitable for grade I-II hemorrhoids, using sclerosing agents to cause fibrosis and tissue shrinkage, with 70-85% short-term efficacy 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, 4
• Bipolar diathermy has 88-100% success rates for bleeding control in grade II hemorrhoids 1

Surgical Management (Grade III-IV Disease or Treatment Failure)

Hemorrhoidectomy is indicated when medical and office-based therapies fail, for symptomatic grade III-IV hemorrhoids, mixed internal-external disease, or concomitant anorectal conditions requiring surgery. 1, 2

Conventional Excisional Hemorrhoidectomy

• Most effective treatment overall with low recurrence rates (2-10%), particularly for grade III-IV hemorrhoids 1, 3, 4
• Closed Ferguson technique may offer slightly improved wound healing and reduced postoperative pain compared to open Milligan-Morgan technique 1, 5
• Major drawback is postoperative pain requiring narcotic analgesics, with most patients not returning to work for 2-4 weeks 1
• Recovery time is 9-14 days, longer than office-based procedures 3

Alternative Surgical Options

• Stapled hemorrhoidopexy shows less postoperative pain, shorter operation time, and faster recovery compared to excisional hemorrhoidectomy, but has a higher recurrence rate and lacks long-term follow-up data 1, 5, 4
• Hemorrhoidal artery ligation (HAL/RAR) demonstrates better tolerance but higher recurrence rates compared to conventional hemorrhoidectomy 5

Grading System and Treatment Algorithm

Internal hemorrhoids are classified into four grades based on prolapse severity: 1

• Grade I: Bleeding but no prolapse → Conservative management, then rubber band ligation if persistent 1, 3
• Grade II: Prolapse with spontaneous reduction → Conservative management, then rubber band ligation if persistent 1, 3
• Grade III: Prolapse requiring manual reduction → Rubber band ligation or surgical hemorrhoidectomy based on response to conservative therapy 1, 3
• Grade IV: Irreducible prolapse → Surgical hemorrhoidectomy 1, 3

Critical Diagnostic Pitfalls

Never attribute all anorectal symptoms to hemorrhoids without proper evaluation, as other conditions are frequently misattributed. 1, 6

• Hemorrhoids alone do not cause positive stool guaiac tests; fecal occult blood should not be attributed to hemorrhoids until the colon is adequately evaluated 1, 6
• Anemia from hemorrhoidal disease is rare (0.5 patients/100,000 population); anemia warrants colonoscopy to rule out proximal colonic pathology 1, 6
• 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, 6
• Anoscopy should be performed when feasible to confirm diagnosis and rule out other anorectal pathology 1, 2
• Colonoscopy is warranted when bleeding is atypical, no hemorrhoidal source is evident on examination, or significant risk factors for colonic neoplasia exist 1, 6

Procedures to Avoid

Anal dilatation should be abandoned due to 52% incontinence rate at 17-year follow-up and sphincter injuries 1, 5

Cryotherapy is rarely used due to prolonged pain, foul-smelling discharge, and greater need for additional therapy 1, 5

When to Refer

Immediate referral indications include: 6

• Anemia from hemorrhoidal bleeding requiring definitive surgical intervention 6
• Severe bleeding with hemodynamic instability 6
• Symptoms persisting >1-2 weeks despite appropriate conservative treatment 6
• Grade IV hemorrhoids always require surgical evaluation 6
• Failure of rubber band ligation or recurrent symptoms after multiple office procedures 6

Special Population: Pregnancy

Safe treatments during pregnancy include: 1, 2

• Dietary fiber, adequate fluid intake, and bulk-forming agents like psyllium husk 1, 2
• Osmotic laxatives (polyethylene glycol or lactulose) 1, 2
• Hydrocortisone foam in the third trimester with no adverse events compared to placebo 1, 2