What are the treatment options for outpatient management of internal hemorrhoids?

From the Guidelines

Outpatient treatment for internal hemorrhoids should begin with non-operative management, including dietary and lifestyle changes, as the first-line therapy, with a strong recommendation based on moderate quality evidence. This approach is supported by the most recent guidelines, such as those from the World Journal of Emergency Surgery 1. The recommended dietary and lifestyle changes include increased fiber and water intake, as well as adequate bathroom habits.

Some key points to consider in the management of internal hemorrhoids include:

• Increased fiber intake to reduce straining during bowel movements
• Adequate hydration to soften stool and reduce straining
• Warm sitz baths for 10-15 minutes several times daily to reduce discomfort and itching
• Avoiding prolonged sitting or straining during bowel movements

If these conservative measures fail, office-based procedures may be necessary, including:

• Rubber band ligation, where small bands are placed around hemorrhoids to cut off circulation, causing them to shrink and fall off within a week
• Sclerotherapy, which involves injecting a chemical solution to shrink the hemorrhoid
• Infrared coagulation, which uses heat to harden and shrink hemorrhoids

These treatments work by reducing blood flow to hemorrhoidal tissue, causing it to shrink and reducing prolapse and bleeding. Most patients can resume normal activities immediately after these procedures, though they may experience mild discomfort for 1-2 days. According to the American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids 1, the choice of treatment depends on the degree of hemorrhoids, patient preference, and physician experience. However, the most recent guidelines from the World Journal of Emergency Surgery 1 prioritize non-operative management as the first-line therapy.

From the Research

Outpatient Treatment Options for Internal Hemorrhoids

• Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is a mainstay of initial therapy for internal hemorrhoids 2
• Dietary modifications, such as increased fiber and water intake, and behavioral therapies, like sitz baths, are also recommended as initial treatments 2, 3
• Office-based treatment with rubber band ligation is the preferred next step for grades I to III internal hemorrhoids if initial therapies are unsuccessful, due to its lower failure rate compared to infrared photocoagulation 2
• Other outpatient treatment options include:
  • Hemorrhoidal artery ligation, which may be useful for grade II or III hemorrhoids, as it can result in less pain and quicker recovery 2, 4
  • Stapled hemorrhoidopexy, which can elevate grade III or IV hemorrhoids to their normal anatomic position, but has potential postoperative complications 2, 4

Considerations for Treatment Selection

• The choice of treatment should be tailored to the individual based on patient preference, convenience, and degree of hemorrhoids 4
• Factors such as degree of discomfort, bleeding, comorbidities, and patient preference should help determine the order in which treatments are pursued 2
• The cost and potential outcomes of different treatment options should also be considered, as newer techniques may not necessarily result in better outcomes compared to traditional interventions 4